Healthcare Provider Details

I. General information

NPI: 1063667947
Provider Name (Legal Business Name): BRIDGEPORT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROUTE 98 W ST STE 105A
NUTTER FORT WV
26301-4385
US

IV. Provider business mailing address

200 ROUTE 98 W ST STE 105A
NUTTER FORT WV
26301-4385
US

V. Phone/Fax

Practice location:
  • Phone: 304-624-0974
  • Fax: 304-624-0979
Mailing address:
  • Phone: 304-624-0974
  • Fax: 304-624-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552382
License Number StateWV

VIII. Authorized Official

Name: SAAD MOSSALLATI
Title or Position: TREASURER
Credential:
Phone: 304-623-5711