Provider Demographics
NPI:1336569458
Name:BRIDGERS, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:BRIDGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2904
Mailing Address - Country:US
Mailing Address - Phone:843-281-8176
Mailing Address - Fax:843-281-8440
Practice Address - Street 1:550 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2904
Practice Address - Country:US
Practice Address - Phone:843-281-8176
Practice Address - Fax:843-281-8440
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist