Healthcare Provider Details

I. General information

NPI: 1003807413
Provider Name (Legal Business Name): PENINSULA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE SUITE 133
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

1414 W FAIR AVE SUITE 133
MARQUETTE MI
49855-2675
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 TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5301010345
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1199700001
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number1003807413
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number5301010345
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010345
License Number StateMI

VIII. Authorized Official

Name: MR. PRAVEEN CHALLA
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 906-225-3902