Provider Demographics
NPI:1194829143
Name:BRIDGEMILL FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:BRIDGEMILL FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-720-0300
Mailing Address - Street 1:10511 BELLS FERRY RD
Mailing Address - Street 2:STE 600
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10511 BELLS FERRY RD
Practice Address - Street 2:STE 600
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4258
Practice Address - Country:US
Practice Address - Phone:770-720-0300
Practice Address - Fax:770-720-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0090633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA653407859AMedicaid
1154830OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA653407859AMedicaid