Provider Demographics
NPI:1316988462
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:RETAIL PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUMBULE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-777-1771
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 1:11306 BEDFORD RD NE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6802
Practice Address - Country:US
Practice Address - Phone:301-777-1771
Practice Address - Fax:301-777-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP000333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420138800Medicaid
MD2105888OtherNABP #
MD0269480001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER