Healthcare Provider Details

I. General information

NPI: 1851795017
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 CATHAGE RD
BERLIN MD
21811
US

IV. Provider business mailing address

11101 CATHAGE RD
BERLIN MD
21811
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-4769
  • Fax: 410-543-4770
Mailing address:
  • Phone: 410-543-4769
  • Fax: 410-543-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06935
License Number StateMD

VIII. Authorized Official

Name: WILLIAM COOPER
Title or Position: AMBULATORY PHARMACY MANAGER,AO
Credential:
Phone: 410-543-7047