Provider Demographics
NPI:1255153680
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AMBULATORY PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:410-543-7047
Mailing Address - Street 1:200 EAST VINE ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801
Mailing Address - Country:US
Mailing Address - Phone:410-543-4798
Mailing Address - Fax:410-543-4799
Practice Address - Street 1:200 EAST VINE ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-543-4798
Practice Address - Fax:410-543-4799
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDALHEALTH PENINSULA REGIONAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy