Provider Demographics
NPI:1679618474
Name:PENINSULA PHARMACY INC
Entity Type:Organization
Organization Name:PENINSULA PHARMACY INC
Other - Org Name:PENINSULA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:JENEMA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-225-3902
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 133
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3902
Mailing Address - Fax:906-226-2661
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3902
Practice Address - Fax:906-226-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006679251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI470E21056OtherBCBS-MI HIT
MI1199700001Medicare ID - Type UnspecifiedMEDICARE NUMBER