Provider Demographics
NPI:1144379611
Name:BEDFORD MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BEDFORD MEMORIAL HOSPITAL
Other - Org Name:BEDFORD MEMORIAL HOSPITAL-PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-4708
Mailing Address - Street 1:PO BOX 13966
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24038-3966
Mailing Address - Country:US
Mailing Address - Phone:540-224-5512
Mailing Address - Fax:540-224-5507
Practice Address - Street 1:1613 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1213
Practice Address - Country:US
Practice Address - Phone:540-224-5512
Practice Address - Fax:540-224-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008530629Medicaid