Provider Demographics
NPI:1528376654
Name:BRIDEWELL, WILLIAM ROBERT
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:BRIDEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 LOUSIANA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-8293
Mailing Address - Country:US
Mailing Address - Phone:307-875-4411
Mailing Address - Fax:307-382-8084
Practice Address - Street 1:70 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5709
Practice Address - Country:US
Practice Address - Phone:307-382-2536
Practice Address - Fax:307-382-8084
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2187183500000X, 1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric