MEDICARE: SAMANTHA JAYNE HOLM PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RPH5596	ND

General Provider Information

NPI Number	:	1497181838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JAYNE HOLM PHARMD

Provider Business Mailing Address
First Line	:	956 6TH AVE NE
Second Line	:
City	:	VALLEY CITY
State	:	ND
Zip	:	58072-2347
Country	:	US
Telephone Number	:	701-430-0180
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 W MAIN ST
Second Line	:
City	:	VALLEY CITY
State	:	ND
Zip	:	58072-3319
Country	:	US
Telephone Number	:	701-845-1763
Fax Number	:	701-845-5171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	07/23/2019

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