Healthcare Provider Details

I. General information

NPI: 1871031559
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E. CARROLL STREET SUITE 1435A
SALISBURY MD
21801
US

IV. Provider business mailing address

1620 W. NORTHWEST HWY SUITE 100
GRAPEVINE TX
76051
US

V. Phone/Fax

Practice location:
  • Phone: 667-330-1065
  • Fax: 410-438-1992
Mailing address:
  • Phone: 817-572-0009
  • Fax: 817-572-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN JORDAN
Title or Position: SR. DIRECTOR OF PHARMACY
Credential:
Phone: 410-749-2825