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General NPI Number Information
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NPI Number | 1144646290
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Entity Type | Organization
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Legal Business Name | PENINSULA PHARMACY PLUS LLC
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Dates
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Enumeration Date | 03/13/2014
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Last Update Date | 02/17/2020
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Provider Practice Location Address
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Address Line | 300 N MCCLELLAN AVE
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City | MARQUETTE
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State | MI
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Zip | 49855-3920
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Country | US
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Telephone | 906-225-1450
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Fax | 906-225-1501
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Provider Business Mailing Address
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Address Line | 300 N MCCLELLAN AVE
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City | MARQUETTE
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State | MI
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Zip | 49855-3920
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Country | US
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Telephone | 906-225-1450
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Fax | 906-225-1501
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TYLER J JENEMA
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Credential | PHARM.D.
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Telephone | 906-225-1450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301010508
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License Number State | MI
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