Provider Demographics
NPI:1982821088
Name:BRIDGE CITY PHARMACY LLC
Entity Type:Organization
Organization Name:BRIDGE CITY PHARMACY LLC
Other - Org Name:BRIDGE CITY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-769-2406
Mailing Address - Street 1:1910 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-2834
Mailing Address - Country:US
Mailing Address - Phone:409-735-5555
Mailing Address - Fax:409-735-7018
Practice Address - Street 1:1910 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-2834
Practice Address - Country:US
Practice Address - Phone:409-735-5555
Practice Address - Fax:409-735-7018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX254573336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100890OtherPK
TX149070Medicaid