Healthcare Provider Details

I. General information

NPI: 1538085949
Provider Name (Legal Business Name): BRIDGEWAY MEDICATION AND SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 TYVOLA RD STE 112
CHARLOTTE NC
28217-3542
US

IV. Provider business mailing address

834 TYVOLA RD STE 112
CHARLOTTE NC
28217-3542
US

V. Phone/Fax

Practice location:
  • Phone: 704-208-1706
  • Fax:
Mailing address:
  • Phone: 704-208-1706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. LATOYA D. GREEN
Title or Position: OWNER
Credential:
Phone: 704-208-1706