Provider Demographics
NPI:1104264779
Name:BRIDGEMAN, ANTHONY THOMAS (RPH)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:THOMAS
Last Name:BRIDGEMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2206
Mailing Address - Country:US
Mailing Address - Phone:608-887-7511
Mailing Address - Fax:
Practice Address - Street 1:822 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2206
Practice Address - Country:US
Practice Address - Phone:608-887-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12512-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist