Provider Demographics
NPI:1851795017
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:TIDALHEALTH HOME SCRIPTS
Other - Org Type:Other Name
Authorized Official - Title/Position:AMBULATORY PHARMACY MANAGER,AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-543-7047
Mailing Address - Street 1:11101 CATHAGE RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:410-543-4769
Mailing Address - Fax:410-543-4770
Practice Address - Street 1:11101 CATHAGE RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-543-4769
Practice Address - Fax:410-543-4770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP069353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153648OtherPK