Provider Demographics
NPI:1629123898
Name:BRIDGE, MARK R (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6240 S 2050 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5233
Mailing Address - Country:US
Mailing Address - Phone:801-479-1779
Mailing Address - Fax:801-479-1835
Practice Address - Street 1:37 N HARRISVILLE RD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-3975
Practice Address - Country:US
Practice Address - Phone:801-621-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86-149110-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist