Healthcare Provider Details

I. General information

NPI: 1538727185
Provider Name (Legal Business Name): BWELL PHARMACY BRIDGETON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12158 NATURAL BRIDGE RD STE C
BRIDGETON MO
63044-4079
US

IV. Provider business mailing address

12158 NATURAL BRIDGE RD STE C
BRIDGETON MO
63044-4079
US

V. Phone/Fax

Practice location:
  • Phone: 314-283-3393
  • Fax:
Mailing address:
  • Phone: 314-283-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TAUQEER HAIDER
Title or Position: OWNER
Credential:
Phone: 314-283-3393