Healthcare Provider Details

I. General information

NPI: 1225920168
Provider Name (Legal Business Name): BLUE BRIDGE SPECIALTY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 KENMOOR AVE SE STE 102
GRAND RAPIDS MI
49546-8626
US

IV. Provider business mailing address

630 KENMOOR AVE SE STE 102
GRAND RAPIDS MI
49546-8626
US

V. Phone/Fax

Practice location:
  • Phone: 616-280-4211
  • Fax: 616-280-4214
Mailing address:
  • Phone: 616-280-4211
  • Fax: 616-280-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MAX BLOOMQUIST
Title or Position: OWNER
Credential:
Phone: 616-280-4211