MEDICARE: PENINSULA PHARMACIES INC LONG BEACH PHARMACY ANNEX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	3336C0004X	Compounding Pharmacy

General Provider Information

NPI Number	:	1063048197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA PHARMACIES INC LONG BEACH PHARMACY ANNEX

Provider Business Mailing Address
First Line	:	PO BOX B
Second Line	:
City	:	ILWACO
State	:	WA
Zip	:	98624-0167
Country	:	US
Telephone Number	:	360-642-1250
Fax Number	:	888-308-2878

Provider Business Practice Location Address
First Line	:	110 OREGON AVE S
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631
Country	:	US
Telephone Number	:	360-642-1250
Fax Number	:	888-308-2878

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFFREY SHANE HARRELL
Credential	:	PHARM D
Telephone Number	:	360-859-8659

Provider Enumeration Date	:	03/20/2020
Last Update Date	:	01/19/2026

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