Provider Demographics
NPI:1558359877
Name:PENINSULA PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:PENINSULA PHARMACY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4600
Mailing Address - Street 1:608 DENBIGH BLVD
Mailing Address - Street 2:STE 800
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4410
Mailing Address - Country:US
Mailing Address - Phone:757-875-7545
Mailing Address - Fax:757-875-7553
Practice Address - Street 1:11833 CANON BLVD
Practice Address - Street 2:STE 114
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2589
Practice Address - Country:US
Practice Address - Phone:757-594-3944
Practice Address - Fax:757-594-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003424251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101131189Medicaid
VA173212OtherANTHEM
VA010143349OtherMEDICAID (DME)
VA173212OtherANTHEM