Provider Demographics
NPI:1437206588
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:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SNEHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAVSAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-791-9000
Mailing Address - Street 1:3201 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3501
Mailing Address - Country:US
Mailing Address - Phone:312-791-9000
Mailing Address - Fax:312-791-9650
Practice Address - Street 1:3201 S WALLACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3501
Practice Address - Country:US
Practice Address - Phone:312-791-9000
Practice Address - Fax:312-791-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540150483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021465OtherPK
IL=========001Medicaid
1476325OtherOTHER ID NUMBER