Provider Demographics
NPI:1265847503
Name:BRIDGEPORT PHARMACY INC
Entity Type:Organization
Organization Name:BRIDGEPORT PHARMACY INC
Other - Org Name:BRIDGEPORT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SALMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-203-4927
Mailing Address - Street 1:527 MEDICAL PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9009
Mailing Address - Country:US
Mailing Address - Phone:304-933-3880
Mailing Address - Fax:304-933-3887
Practice Address - Street 1:527 MEDICAL PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:304-933-3880
Practice Address - Fax:304-933-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148743OtherPK