Organization
PENINSULA PHARMACY INC
Active
Other names
PENINSULA PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PRAVEEN CHALLA R.PH. (PRESIDENT)
(906) 225-3902
Entity
Organization
Contact information
Practice address
1414 W FAIR AVE, SUITE 133, MARQUETTE, MI 49855-2675
(906) 225-3902
(906) 226-2661
Mailing address
1414 W FAIR AVE, SUITE 133, MARQUETTE, MI 49855-2675
(906) 225-3902
(906) 226-2661
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
5301010345
MI
332B00000X
Durable Medical Equipment & Medical Supplies
1199700001
MI
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
1003807413
MI
3336C0003X
Community/Retail Pharmacy
Primary
5301010345
MI
3336H0001X
Home Infusion Therapy Pharmacy
5301010345
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1003807413
BCBS - MICHIGAN
MI
01
—
2357362
NCPDP
MI
05
—
3409001
—
MI
Enumeration date
11/03/2005
Last updated
12/18/2024
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