Provider Demographics
NPI:1114917242
Name:BRIDGEPORT PHARMACY INC
Entity Type:Organization
Organization Name:BRIDGEPORT PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST/IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BOETTCHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:989-777-2900
Mailing Address - Street 1:6224 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9513
Mailing Address - Country:US
Mailing Address - Phone:989-777-2900
Mailing Address - Fax:989-777-4649
Practice Address - Street 1:6224 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9513
Practice Address - Country:US
Practice Address - Phone:989-777-2900
Practice Address - Fax:989-777-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2359998Medicaid
MI2359998Medicaid