Provider Demographics
NPI:1275615106
Name:PENINSULA PHARMACIES INC
Entity Type:Organization
Organization Name:PENINSULA PHARMACIES INC
Other - Org Name:LONG BEACH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-244-5984
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:101 BOLSTAD AVE
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631
Mailing Address - Country:US
Mailing Address - Phone:360-642-2349
Mailing Address - Fax:360-642-8786
Practice Address - Street 1:101 BOLSTAD AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631
Practice Address - Country:US
Practice Address - Phone:360-642-2349
Practice Address - Fax:360-642-8786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000004973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6085609Medicaid