=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093449829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEWART BRIDGER PD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2022
-----------------------------------------------------
Last Update Date | 07/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4015 W WEDINGTON DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-442-2561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 S 26TH PL APT 2314
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-4251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-919-4005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD16257
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------