Provider Demographics
NPI:1063048197
Name:PENINSULA PHARMACIES INC LONG BEACH PHARMACY ANNEX
Entity type:Organization
Organization Name:PENINSULA PHARMACIES INC LONG BEACH PHARMACY ANNEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:360-244-5984
Mailing Address - Street 1:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0167
Mailing Address - Country:US
Mailing Address - Phone:360-642-1250
Mailing Address - Fax:
Practice Address - Street 1:110 OREGON AVE S
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631
Practice Address - Country:US
Practice Address - Phone:360-642-1250
Practice Address - Fax:888-308-2878
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENINSULA PHARMACIES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy