Provider Demographics
NPI:1871031559
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-749-2825
Mailing Address - Street 1:1620 W. NORTHWEST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-572-0221
Practice Address - Street 1:100 E. CARROLL STREET
Practice Address - Street 2:SUITE 1435A
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:667-330-1065
Practice Address - Fax:410-438-1992
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDALHEALTH PENINSULA REGIONAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-02
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy