Active NPI
Peninsula Pharmacy Inc
Doing business as Peninsula Pharmacy
- Community/Retail Pharmacy
- Marquette, MI
National Provider Identifier
1003807413
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- 5301010345
- Legal business name
- PENINSULA PHARMACY INC
- Doing business as
- Peninsula Pharmacy
- Practice address
- 1414 W Fair Ave
Suite 133
Marquette, MI 49855-2675 - Phone
- (906) 225-3902
- Fax
- (906) 226-2661
- NPI assigned
- Nov 3, 2005
- Last updated
- Dec 18, 2024
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. Praveen Challa, R.PH.
- Title
- President
- Phone
- (906) 225-3902
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 5301010345 | MI | |
| Durable Medical Equipment & Medical Supplies | 332B00000X | 1199700001 | MI | |
| Parenteral & Enteral Nutrition Supplies (DME) | 332BP3500X | 1003807413 | MI | |
| Community/Retail Pharmacy | 3336C0003X | 5301010345 | MI | Primary |
| Home Infusion Therapy Pharmacy | 3336H0001X | 5301010345 | MI |
Addresses
Primary practice location
1414 W Fair Ave
Suite 133
Marquette, MI 49855-2675
Mailing address
1414 W Fair Ave
Suite 133
Marquette, MI 49855-2675
Phone (906) 225-3902
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003807413 | Other | MI | BCBS - MICHIGAN |
| 3409001 | Medicaid | MI | |
| 2357362 | Other | MI | NCPDP |
Other names 1
- PENINSULA PHARMACY
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930091074 | MI | DME Supplier - Pharmacy | 6709907553 | Practice locations: Marquette, MI |
| O20240105000543 | MI | Part B Supplier - Pharmacy | 6709907553 | Practice locations: Marquette, MI |
National Provider Directory
National Provider Directory- Tax ID family
- Peninsula Pharmacy
Other organizations with this tax ID 2
Organizations that report the same tax identification number in the National Provider Directory.
Member organizations 1
Organizations listed as members of this organization in the National Provider Directory.
-
dba Peninsula Pharmacy Plus
- Community/Retail Pharmacy
- Marquette, MI
- NPI 1144646290
Member Of
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1130976000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1734480000000",
"number": "1003807413",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1414 W FAIR AVE",
"address_2": "SUITE 133",
"city": "MARQUETTE",
"state": "MI",
"postal_code": "498552675",
"telephone_number": "906-225-3902",
"fax_number": "906-226-2661"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1414 W FAIR AVE",
"address_2": "SUITE 133",
"city": "MARQUETTE",
"state": "MI",
"postal_code": "498552675",
"telephone_number": "906-225-3902",
"fax_number": "906-226-2661"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "PENINSULA PHARMACY INC",
"organizational_subpart": "NO",
"enumeration_date": "2005-11-03",
"last_updated": "2024-12-18",
"certification_date": "2024-12-18",
"status": "A",
"authorized_official_last_name": "CHALLA",
"authorized_official_first_name": "PRAVEEN",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "906-225-3902",
"authorized_official_name_prefix": "Mr.",
"authorized_official_credential": "R.PH."
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MI",
"license": "5301010345",
"primary": false
},
{
"code": "332B00000X",
"taxonomy_group": "",
"desc": "Durable Medical Equipment & Medical Supplies",
"state": "MI",
"license": "1199700001",
"primary": false
},
{
"code": "332BP3500X",
"taxonomy_group": "",
"desc": "Durable Medical Equipment & Medical Supplies, Parenteral & Enteral Nutrition",
"state": "MI",
"license": "1003807413",
"primary": false
},
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "MI",
"license": "5301010345",
"primary": true
},
{
"code": "3336H0001X",
"taxonomy_group": "",
"desc": "Pharmacy, Home Infusion Therapy Pharmacy",
"state": "MI",
"license": "5301010345",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS - MICHIGAN",
"identifier": "1003807413",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3409001",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NCPDP",
"identifier": "2357362",
"state": "MI"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "PENINSULA PHARMACY",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "PENINSULA PHARMACY",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Marquette, MI
- Mary M Pelton Cooper, PSYD
- Jamie Marie Pendy, MD
- Peninsula Advanced Care Pharmacy LLC
- Peninsula Family Dentistry, PC
- Peninsula Pharmacy Health Systems Campus LLC
- Peninsula Pharmacy Inc (Peninsula Pharmacy)
- Peninsula Pharmacy Inc. (Peninsula Pharmacy)
- Peninsula Pharmacy Plus LLC (Peninsula Pharmacy Plus)
- Brad Pennala, CPT/CHW
- Elizabeth Lee Peppin, PA-C
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.