Provider Demographics
NPI:1447482757
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:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CORWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-723-2423
Mailing Address - Street 1:3 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1058
Mailing Address - Country:US
Mailing Address - Phone:301-777-1773
Mailing Address - Fax:301-777-7109
Practice Address - Street 1:12502 WILLOWBROOK RD STE 203
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:301-759-0203
Practice Address - Fax:301-759-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP050723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121817OtherPK
WV3810016226Medicaid
MD418496300Medicaid
MD418496300Medicaid