Provider Demographics
NPI:1669901815
Name:BRIDGE HEALTHCARE PHARMACY LLC
Entity type:Organization
Organization Name:BRIDGE HEALTHCARE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-467-3510
Mailing Address - Street 1:P.O. BOX 22
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074
Mailing Address - Country:US
Mailing Address - Phone:269-467-3510
Mailing Address - Fax:269-467-3515
Practice Address - Street 1:658 E. MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-3510
Practice Address - Fax:269-467-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy