Provider Demographics
NPI:1215611959
Name:PENINSULA PHARMACY GLADSTONE LLC
Entity type:Organization
Organization Name:PENINSULA PHARMACY GLADSTONE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
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 STE 133
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5408
Mailing Address - Country:US
Mailing Address - Phone:906-225-3902
Mailing Address - Fax:906-226-2661
Practice Address - Street 1:117 N 9TH ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1644
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:2023-06-13
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy