Provider Demographics
NPI:1073919049
Name:PENINSULA PHARMACY HEALTH SYSTEMS CAMPUS LLC
Entity Type:Organization
Organization Name:PENINSULA PHARMACY HEALTH SYSTEMS CAMPUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENEMA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:906-869-0999
Mailing Address - Street 1:300 N MCCLELLAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2736
Practice Address - Country:US
Practice Address - Phone:906-869-0999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy