Provider Demographics
NPI:1225920168
Name:BLUE BRIDGE SPECIALTY PHARMACY, LLC
Entity type:Organization
Organization Name:BLUE BRIDGE SPECIALTY PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOMQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-280-4211
Mailing Address - Street 1:630 KENMOOR AVE SE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8626
Mailing Address - Country:US
Mailing Address - Phone:616-280-4211
Mailing Address - Fax:616-280-4214
Practice Address - Street 1:630 KENMOOR AVE SE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8626
Practice Address - Country:US
Practice Address - Phone:616-280-4211
Practice Address - Fax:616-280-4214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-16
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251F00000XAgenciesHome Infusion
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy