Provider Demographics
NPI:1003354614
Name:BRIDGESTONE PHARMACY LLC
Entity type:Organization
Organization Name:BRIDGESTONE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-930-1553
Mailing Address - Street 1:825 HAMILTON CROSSINGS
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013
Mailing Address - Country:US
Mailing Address - Phone:615-930-1553
Mailing Address - Fax:615-250-4918
Practice Address - Street 1:825 HAMILTON CROSSINGS
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013
Practice Address - Country:US
Practice Address - Phone:615-930-1553
Practice Address - Fax:615-250-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X, 333600000X
TN00000059443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168470OtherPK