Healthcare Provider Details

I. General information

NPI: 1215611959
Provider Name (Legal Business Name): PENINSULA PHARMACY GLADSTONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N 9TH ST
GLADSTONE MI
49837-1644
US

IV. Provider business mailing address

1414 W FAIR AVE STE 133
MARQUETTE MI
49855-5408
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3902
  • Fax: 906-226-2661
Mailing address:
  • Phone: 906-225-3902
  • Fax: 906-226-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TYLER J JENEMA
Title or Position: PHARMACIST
Credential: PHARM.D.
Phone: 906-225-3902