Provider Demographics
NPI:1861565855
Name:PENINSULA PHARMACY SERVICES
Entity type:Organization
Organization Name:PENINSULA PHARMACY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-3944
Mailing Address - Street 1:11833 CANON BLVD
Mailing Address - Street 2:STE 114
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2589
Mailing Address - Country:US
Mailing Address - Phone:757-594-3944
Mailing Address - Fax:757-594-3950
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:2006-11-16
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010143349Medicaid