MEDICARE: JOHN THEODORE SAMUELSON PHARMACIST

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	111321-3	MN

General Provider Information

NPI Number	:	1831194620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN THEODORE SAMUELSON PHARMACIST

Provider Business Mailing Address
First Line	:	710 MEADOW LN
Second Line	:
City	:	STARBUCK
State	:	MN
Zip	:	56381-4504
Country	:	US
Telephone Number	:	320-239-4361
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 W. 5TH ST., BOX 399
Second Line	:
City	:	STARBUCK
State	:	MN
Zip	:	56381-0399
Country	:	US
Telephone Number	:	320-239-2246
Fax Number	:	320-239-2296

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	07/08/2007

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