Provider Demographics
NPI:1063590073
Name:PENINSULA HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:PENINSULA HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HASKELL
Authorized Official - Last Name:TRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD MPH
Authorized Official - Phone:757-594-7305
Mailing Address - Street 1:416 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601
Mailing Address - Country:US
Mailing Address - Phone:757-594-7431
Mailing Address - Fax:757-594-7199
Practice Address - Street 1:416 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601
Practice Address - Country:US
Practice Address - Phone:757-594-7431
Practice Address - Fax:757-594-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010005103336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4807383OtherNABP
VA8507864Medicaid