Provider Demographics
NPI:1184904450
Name:BEDFORD ROAD PHARMACY, INC.
Entity type:Organization
Organization Name:BEDFORD ROAD PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:BALCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-723-2405
Mailing Address - Street 1:11306 BEDFORD RD NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6802
Mailing Address - Country:US
Mailing Address - Phone:301-723-2444
Mailing Address - Fax:301-777-0119
Practice Address - Street 1:1219A NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7602
Practice Address - Country:US
Practice Address - Phone:301-729-1780
Practice Address - Fax:301-729-1783
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEDFORD ROAD PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420138800Medicaid