Provider Demographics
NPI:1891770038
Name:PENINSULA PROFESSIONAL CENTER PHARMACY
Entity Type:Organization
Organization Name:PENINSULA PROFESSIONAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:650-692-3977
Mailing Address - Street 1:1828 EL CAMINO REAL
Mailing Address - Street 2:PENINSULA PROFESSIONAL CENTER PHARMACY
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3103
Mailing Address - Country:US
Mailing Address - Phone:650-692-3977
Mailing Address - Fax:650-692-3978
Practice Address - Street 1:1828 EL CAMINO REAL
Practice Address - Street 2:PENINSULA PROFESSIONAL CENTER PHARMACY
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3103
Practice Address - Country:US
Practice Address - Phone:650-692-3977
Practice Address - Fax:650-692-3978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY17946333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy