Healthcare Provider Details

I. General information

NPI: 1356308480
Provider Name (Legal Business Name): BRIDGEPORT PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6226 DIXIE HWY
BRIDGEPORT MI
48722-9513
US

IV. Provider business mailing address

6226 DIXIE HWY
BRIDGEPORT MI
48722-9513
US

V. Phone/Fax

Practice location:
  • Phone: 989-777-3286
  • Fax: 989-777-3384
Mailing address:
  • Phone: 989-777-3286
  • Fax: 989-777-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number10657A
License Number StateMI

VIII. Authorized Official

Name: MRS. KAREN MARIE BOETTCHER
Title or Position: VICE PRESIDENT
Credential:
Phone: 989-777-3286