Provider Demographics
NPI:1356393771
Name:BRIDGERS DRUG STORE & GIFTS LLC
Entity type:Organization
Organization Name:BRIDGERS DRUG STORE & GIFTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-423-2682
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-0850
Mailing Address - Country:US
Mailing Address - Phone:843-423-2682
Mailing Address - Fax:843-423-2429
Practice Address - Street 1:305 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-3027
Practice Address - Country:US
Practice Address - Phone:843-423-2682
Practice Address - Fax:843-423-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4205503Medicaid
SC6491920001Medicare NSC