Provider Demographics
NPI:1104423870
Name:PENINSULA PHARMACIES INC.
Entity type:Organization
Organization Name:PENINSULA PHARMACIES INC.
Other - Org Name:<UNAVAIL>
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:
Authorized Official - Phone:360-642-3133
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:360-642-3133
Mailing Address - Fax:360-642-5133
Practice Address - Street 1:101 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9100
Practice Address - Country:US
Practice Address - Phone:360-642-3133
Practice Address - Fax:360-642-5133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy