Provider Demographics
NPI:1760617997
Name:PENINSULA COMMUNITY HEALTH SERVICES
Entity Type:Organization
Organization Name:PENINSULA COMMUNITY HEALTH SERVICES
Other - Org Name:PENINSULA COMMUNITY HEALTH SERVICES PHARMACY-POULSBO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KREIDLER-MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-478-2366
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0212
Mailing Address - Country:US
Mailing Address - Phone:360-475-3731
Mailing Address - Fax:360-475-3730
Practice Address - Street 1:19917 7TH AVE NE STE 205
Practice Address - Street 2:SUITE 205
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6555
Practice Address - Country:US
Practice Address - Phone:360-697-7636
Practice Address - Fax:360-697-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF600841203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6032270Medicaid
2120260OtherPK