Provider Demographics
NPI:1356308480
Name:BRIDGEPORT PHARMACY, INC
Entity Type:Organization
Organization Name:BRIDGEPORT PHARMACY, INC
Other - Org Name:BRIDGEPORT HOME MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOETTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-777-3286
Mailing Address - Street 1:6226 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:989-777-3286
Mailing Address - Fax:989-777-3384
Practice Address - Street 1:6226 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:989-777-3286
Practice Address - Fax:989-777-3384
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGEPORT PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-01
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10657A332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4226131Medicaid
MI0G30386OtherBLUE CROSS BLUE SHIELD
MI1300560001Medicare NSC