Healthcare Provider Details

I. General information

NPI: 1629123898
Provider Name (Legal Business Name): MARK R BRIDGE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 N HARRISVILLE RD
OGDEN UT
84404-3975
US

IV. Provider business mailing address

6240 S 2050 E
OGDEN UT
84403-5233
US

V. Phone/Fax

Practice location:
  • Phone: 801-621-2532
  • Fax:
Mailing address:
  • Phone: 801-479-1779
  • Fax: 801-479-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number86-149110-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: