Provider Demographics
NPI:1366482382
Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH
Entity type:Organization
Organization Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-591-0643
Mailing Address - Street 1:1033 28TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4233
Mailing Address - Country:US
Mailing Address - Phone:757-952-0176
Mailing Address - Fax:757-952-0181
Practice Address - Street 1:1033 28TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607-4233
Practice Address - Country:US
Practice Address - Phone:757-952-0176
Practice Address - Fax:757-952-0181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENINSULA INSTITUTE FOR COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0201004012OtherPHARMACY PERMIT
VABP9712678OtherDEA REGISTRATION NUMBER