Healthcare Provider Details

I. General information

NPI: 1497181838
Provider Name (Legal Business Name): SAMANTHA JAYNE HOLM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
VALLEY CITY ND
58072-3319
US

IV. Provider business mailing address

956 6TH AVE NE
VALLEY CITY ND
58072-2347
US

V. Phone/Fax

Practice location:
  • Phone: 701-845-1763
  • Fax: 701-845-5171
Mailing address:
  • Phone: 701-430-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5596
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: