Provider Demographics
NPI:1669532073
Name:BRIDGES, NATHAN GREEN
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:GREEN
Last Name:BRIDGES
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 1:718 E 25 S
Mailing Address - Street 2:718 E 25 S
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1223
Mailing Address - Country:US
Mailing Address - Phone:801-699-9029
Mailing Address - Fax:
Practice Address - Street 1:777 N MAIN ST
Practice Address - Street 2:777 N MAIN
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1165
Practice Address - Country:US
Practice Address - Phone:435-283-8194
Practice Address - Fax:435-283-8205
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5032957-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist