Healthcare Provider Details

I. General information

NPI: 1114917242
Provider Name (Legal Business Name): BRIDGEPORT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 DIXIE HWY
BRIDGEPORT MI
48722-9513
US

IV. Provider business mailing address

6224 DIXIE HWY
BRIDGEPORT MI
48722-9513
US

V. Phone/Fax

Practice location:
  • Phone: 989-777-2900
  • Fax: 989-777-4649
Mailing address:
  • Phone: 989-777-2900
  • Fax: 989-777-4649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025343
License Number StateMI

VIII. Authorized Official

Name: MR. RAYMOND WILLIAM BOETTCHER JR.
Title or Position: REGISTERED PHARMACIST/IN CHARGE
Credential:
Phone: 989-777-2900