Provider Demographics
NPI:1063667947
Name:BRIDGEPORT PHARMACY INC
Entity Type:Organization
Organization Name:BRIDGEPORT PHARMACY INC
Other - Org Name:MEDWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SAAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSALLATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-623-5711
Mailing Address - Street 1:200 ROUTE 98 W ST
Mailing Address - Street 2:STE 105A
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4385
Mailing Address - Country:US
Mailing Address - Phone:304-624-0974
Mailing Address - Fax:304-624-0979
Practice Address - Street 1:200 ROUTE 98 W ST
Practice Address - Street 2:STE 105A
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4385
Practice Address - Country:US
Practice Address - Phone:304-624-0974
Practice Address - Fax:304-624-0979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05523823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118653OtherPK