Provider Demographics
NPI:1619408424
Name:PENINSULA PHARMACY ESCANABA LLC
Entity type:Organization
Organization Name:PENINSULA PHARMACY ESCANABA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENEMA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:906-225-3902
Mailing Address - Street 1:1414 W. FAIR AVE
Mailing Address - Street 2:STE 133
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3902
Mailing Address - Fax:906-226-2661
Practice Address - Street 1:2500 7TH AVE S
Practice Address - Street 2:STE 200
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1292
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:2017-03-23
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy