Healthcare Provider Details

I. General information

NPI: 1174626550
Provider Name (Legal Business Name): MYTILINI ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 ROUTE 101
BEDFORD NH
03110-5440
US

IV. Provider business mailing address

209 ROUTE 101
BEDFORD NH
03110-5440
US

V. Phone/Fax

Practice location:
  • Phone: 603-472-3919
  • Fax: 603-472-7448
Mailing address:
  • Phone: 603-472-3919
  • Fax: 603-472-7448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHARLES FANARAS
Title or Position: PRESIDENT
Credential:
Phone: 603-224-9591