Provider Demographics
NPI:1659989861
Name:IVEY, BRIDGET BEAUSHA
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:BEAUSHA
Last Name:IVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E 11TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6219
Mailing Address - Country:US
Mailing Address - Phone:706-936-8561
Mailing Address - Fax:
Practice Address - Street 1:4851 WHITESBURG DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1626
Practice Address - Country:US
Practice Address - Phone:256-650-2396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist