NPIMap

Organization Active NPI

Peninsula Pharmacy Inc.

Doing business as Peninsula Pharmacy

  • Long Term Care Pharmacy
  • Marquette, MI
National Provider Identifier
1366943995
Registry record updated Dec 18, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Long Term Care PharmacyTaxonomy code 3336L0003X
Legal business name
PENINSULA PHARMACY INC.
Doing business as
Peninsula Pharmacy
Practice address
1414 W Fair Ave Ste 133
Marquette, MI 49855-5408
Phone
(906) 225-3902
NPI assigned
Feb 28, 2018
Last updated
Dec 18, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Praveen J Challa, PHARMD
Title
Owner
Phone
(906) 225-3902

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Long Term Care Pharmacy 3336L0003X NU Primary

Addresses

Primary practice location

1414 W Fair Ave Ste 133
Marquette, MI 49855-5408

Mailing address

1414 W Fair Ave Ste 133
Marquette, MI 49855-5408
Phone (906) 225-3902

Other identifiers 1

IdentifierTypeStateIssuer
3408990MedicaidMI

Other names 1

  • Peninsula Pharmacy Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Peninsula Pharmacy3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1519776000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1734480000000",
    "number": "1366943995",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1414 W FAIR AVE STE 133",
            "city": "MARQUETTE",
            "state": "MI",
            "postal_code": "498555408",
            "telephone_number": "906-225-3902"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1414 W FAIR AVE STE 133",
            "city": "MARQUETTE",
            "state": "MI",
            "postal_code": "498555408",
            "telephone_number": "906-225-3902"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENINSULA PHARMACY INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-28",
        "last_updated": "2024-12-18",
        "certification_date": "2024-12-18",
        "status": "A",
        "authorized_official_last_name": "CHALLA",
        "authorized_official_first_name": "PRAVEEN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "906-225-3902",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3408990",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peninsula Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marquette, MI

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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.