Healthcare Provider Details

I. General information

NPI: 1275615106
Provider Name (Legal Business Name): PENINSULA PHARMACIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BOLSTAD AVE
LONG BEACH WA
98631
US

IV. Provider business mailing address

PO BOX 187 101 BOLSTAD AVE
LONG BEACH WA
98631
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-2349
  • Fax: 360-642-8786
Mailing address:
  • Phone: 360-642-2349
  • Fax: 360-642-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCF00000497
License Number StateWA

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: PRESIDENT
Credential:
Phone: 360-244-5984