Healthcare Provider Details

I. General information

NPI: 1063048197
Provider Name (Legal Business Name): PENINSULA PHARMACIES INC LONG BEACH PHARMACY ANNEX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 OREGON AVE S
LONG BEACH WA
98631
US

IV. Provider business mailing address

PO BOX B
ILWACO WA
98624-0167
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-1250
  • Fax: 888-308-2878
Mailing address:
  • Phone: 360-642-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

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