Provider Demographics
NPI:1588821789
Name:BRIDGEPORT PHARMACY LLC
Entity Type:Organization
Organization Name:BRIDGEPORT PHARMACY LLC
Other - Org Name:BRIDGEPORT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:APPALANENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-568-9000
Mailing Address - Street 1:978 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1913
Mailing Address - Country:US
Mailing Address - Phone:203-367-9000
Mailing Address - Fax:203-367-9004
Practice Address - Street 1:978 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1913
Practice Address - Country:US
Practice Address - Phone:203-367-9000
Practice Address - Fax:203-367-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY.00021153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002934OtherPK
0721159OtherNCPDP PROVIDER IDENTIFICATION NUMBER