Healthcare Provider Details

I. General information

NPI: 1457605933
Provider Name (Legal Business Name): BEDFORD ROAD PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 FRANKFORT HIGHWAY
FORT ASHBY WV
26719
US

IV. Provider business mailing address

3 COMMERCE DR
CUMBERLAND MD
21502-1058
US

V. Phone/Fax

Practice location:
  • Phone: 123-456-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN BALCH
Title or Position: PRESIDENT
Credential: RPH
Phone: 301-723-2405