Provider Demographics
NPI:1427194570
Name:BRIDGE STREET PHARMACY INC
Entity type:Organization
Organization Name:BRIDGE STREET PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:GILL
Authorized Official - Last Name:RIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:336-835-3131
Mailing Address - Street 1:817 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-3008
Mailing Address - Country:US
Mailing Address - Phone:336-835-3131
Mailing Address - Fax:336-835-2358
Practice Address - Street 1:817 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-3008
Practice Address - Country:US
Practice Address - Phone:336-835-3131
Practice Address - Fax:336-835-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07272332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0865428Medicaid
VA1427194570Medicaid
NC7795398Medicaid
NC7701236Medicaid
NC7795397Medicaid