Healthcare Provider Details

I. General information

NPI: 1528376654
Provider Name (Legal Business Name): MR. WILLIAM ROBERT BRIDEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 GATEWAY BLVD
ROCK SPRINGS WY
82901-5709
US

IV. Provider business mailing address

1105 LOUSIANA CIRCLE
GREEN RIVER WY
82935-8293
US

V. Phone/Fax

Practice location:
  • Phone: 307-382-2536
  • Fax: 307-382-8084
Mailing address:
  • Phone: 307-875-4411
  • Fax: 307-382-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2187
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number2187
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: