Healthcare Provider Details

I. General information

NPI: 1558359877
Provider Name (Legal Business Name): PENINSULA PHARMACY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11833 CANON BLVD STE 114
NEWPORT NEWS VA
23606-2589
US

IV. Provider business mailing address

608 DENBIGH BLVD STE 800
NEWPORT NEWS VA
23608-4410
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-3944
  • Fax: 757-594-3950
Mailing address:
  • Phone: 757-875-7545
  • Fax: 757-875-7553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number0201003424
License Number StateVA

VIII. Authorized Official

Name: MIKE BOGGS
Title or Position: ADMINISTRATOR
Credential:
Phone: 757-594-4600