Provider Demographics
NPI:1851717557
Name:BRIDGEPORT PRESCRIPTION SHOP LLC
Entity Type:Organization
Organization Name:BRIDGEPORT PRESCRIPTION SHOP LLC
Other - Org Name:COMMUNITY PHARMACY OF BRIDGEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:304-695-0572
Mailing Address - Street 1:1212 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1354
Mailing Address - Country:US
Mailing Address - Phone:304-842-3223
Mailing Address - Fax:
Practice Address - Street 1:1212 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1354
Practice Address - Country:US
Practice Address - Phone:304-842-3223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy