Healthcare Provider Details

I. General information

NPI: 1255153680
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EAST VINE ST
SALISBURY MD
21801
US

IV. Provider business mailing address

200 EAST VINE ST
SALISBURY MD
21801
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-4798
  • Fax: 410-543-4799
Mailing address:
  • Phone: 410-543-4798
  • Fax: 410-543-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM CLIFFORD COOPER
Title or Position: DIRECTOR OF AMBULATORY PHARMACY
Credential: P.D.
Phone: 410-543-7047