NPIMap

Organization Active NPI

Peninsula Pharmacies Inc

  • Community/Retail Pharmacy
  • Ilwaco, WA
National Provider Identifier
1255416038
Registry record updated Jul 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
CF00000398 Issued in WA
Legal business name
PENINSULA PHARMACIES INC
Practice address
101 1St Ave South
Ilwaco, WA 98624
Phone
(360) 642-3133
Fax
(360) 642-5133
NPI assigned
Oct 27, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 7, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Tom Sutherland, RPH
Title
Pharmacist
Phone
(360) 642-3133

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X CF00000398 WA Primary

Addresses

Primary practice location

101 1St Ave South
Ilwaco, WA 98624

Mailing address

PO Box B
Ilwaco, WA 98624-0167
Phone (360) 642-3133

Other practice location 1

117 Spruce St E
Ilwaco, WA 98624-9174
Phone (360) 642-3133 ext. 627

Other identifiers 4

IdentifierTypeStateIssuer
50D0957411OtherWAWA CLIA
50D2201997OtherWAWA CLIA
GAB10691OtherWANORIDIAN / MEDICARE
6134001MedicaidWA

Other names 1

  • Ilwaco Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040401000877 WA Part B Supplier - Pharmacy 8325030083 Practice locations: Ilwaco, WA
O20100930051976 WA DME Supplier - Pharmacy 8325030083 Practice locations: Ilwaco, WA
O20201211001690 WA Part B Supplier - Independent Clinical Laboratory 8325030083 Practice locations: Ilwaco, WA

National Provider Directory

National Provider Directory
Tax ID family
Peninsula Pharmacies Inc Long Beach Pharmacy Annex5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

101 Bolstad Ave E
Long Beach, WA 98631
Phone (360) 642-2349

1501 Bay Ave
Ocean Park, WA 98640
Phone (360) 665-5181

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161907200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1625616000000",
    "number": "1255416038",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX B",
            "city": "ILWACO",
            "state": "WA",
            "postal_code": "986240167",
            "telephone_number": "360-642-3133",
            "fax_number": "360-642-5133"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 1ST AVE SOUTH",
            "city": "ILWACO",
            "state": "WA",
            "postal_code": "98624",
            "telephone_number": "360-642-3133",
            "fax_number": "360-642-5133"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "117 Spruce St E",
            "address_purpose": "LOCATION",
            "city": "Ilwaco",
            "state": "WA",
            "postal_code": "986249174",
            "country_code": "US",
            "telephone_number": "360-642-3133 x627",
            "fax_number": "360-642-5133",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PENINSULA PHARMACIES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-27",
        "last_updated": "2021-07-07",
        "certification_date": "2021-07-07",
        "status": "A",
        "authorized_official_last_name": "SUTHERLAND",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "PHARMACIST",
        "authorized_official_telephone_number": "360-642-3133",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WA",
            "license": "CF00000398",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WA CLIA",
            "identifier": "50D0957411",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WA CLIA",
            "identifier": "50D2201997",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NORIDIAN / MEDICARE",
            "identifier": "GAB10691",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6134001",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ilwaco Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ilwaco Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ilwaco, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.