Provider Demographics
NPI:1295777597
Name:BRIDGEPORT ALLENMORE LLC
Entity type:Organization
Organization Name:BRIDGEPORT ALLENMORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-238-2230
Mailing Address - Street 1:7424 BRIDGEPORT WAY W
Mailing Address - Street 2:STE 207
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 S CEDAR ST
Practice Address - Street 2:STE 104
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2308
Practice Address - Country:US
Practice Address - Phone:253-582-2293
Practice Address - Fax:253-272-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00057481333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6014518Medicaid
4912968OtherOTHER ID NUMBER-COMMERCIAL NUMBER