MEDICARE: JENNA M WAHLSTROM 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	RPH5577	ND

General Provider Information

NPI Number	:	1144668104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA M WAHLSTROM PHARMD

Provider Business Mailing Address
First Line	:	244 N MAIN ST
Second Line	:	PO BOX 550
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-7124
Country	:	US
Telephone Number	:	701-444-2410
Fax Number	:	701-444-2921

Provider Business Practice Location Address
First Line	:	244 N MAIN ST
Second Line	:
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-7124
Country	:	US
Telephone Number	:	701-444-2410
Fax Number	:	701-444-2921

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

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	06/11/2013

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