Provider Demographics
NPI:1376088443
Name:MYTILINI ENTERPRISES
Entity Type:Organization
Organization Name:MYTILINI ENTERPRISES
Other - Org Name:BEDFORD PHARMACY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANARAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-224-9591
Mailing Address - Street 1:209 ROUTE 101
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-5440
Mailing Address - Country:US
Mailing Address - Phone:603-472-3919
Mailing Address - Fax:603-472-7448
Practice Address - Street 1:209 ROUTE 101
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5440
Practice Address - Country:US
Practice Address - Phone:603-472-3919
Practice Address - Fax:603-472-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy