Healthcare Provider Details

I. General information

NPI: 1770665754
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: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BAY AVE
OCEAN PARK WA
98640-4203
US

IV. Provider business mailing address

PO BOX 206 1501 BAY AVE
OCEAN PARK WA
98640-0206
US

V. Phone/Fax

Practice location:
  • Phone: 360-665-5181
  • Fax: 360-665-6264
Mailing address:
  • Phone: 360-665-5181
  • Fax: 360-665-6264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCF00002166
License Number StateWA

VIII. Authorized Official

Name: DR. JEFFREY SHANE HARRELL
Title or Position: PHARMACIST OWNER
Credential: PHARMD
Phone: 360-665-5181