Provider Demographics
NPI:1861640526
Name:ROWAN, BRIDGET O
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:O
Last Name:ROWAN
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 1:55 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12816-1021
Mailing Address - Country:US
Mailing Address - Phone:518-677-3484
Mailing Address - Fax:518-677-2319
Practice Address - Street 1:55 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-1021
Practice Address - Country:US
Practice Address - Phone:518-677-3484
Practice Address - Fax:518-677-2319
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039739-1183500000X
VT0330003050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02829821Medicaid
3354646OtherNABP
NY02829821Medicaid