Provider Demographics
NPI:1962910737
Name:BRIDGEMAN, TARA MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:BRIDGEMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:HAWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7250 GUIDER DRIVE
Mailing Address - Street 2:APT 209
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-253-9454
Mailing Address - Fax:
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751
Practice Address - Country:US
Practice Address - Phone:715-233-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123004183500000X
WI18426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist