Provider Demographics
NPI:1629368543
Name:PACK, BRIDGETT NICOLE (PHARM D)
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:NICOLE
Last Name:PACK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21309 JESSICA LN
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7701
Mailing Address - Country:US
Mailing Address - Phone:276-608-6670
Mailing Address - Fax:276-783-8993
Practice Address - Street 1:340 BAGLEY CIR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354
Practice Address - Country:US
Practice Address - Phone:276-783-1215
Practice Address - Fax:276-783-8993
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist