Provider Demographics
NPI:1003437369
Name:BRENTRUP, SAMANTHA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BRENTRUP
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 14TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2958
Mailing Address - Country:US
Mailing Address - Phone:701-290-9717
Mailing Address - Fax:
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:218-281-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124146OtherPHARMACIST LICENSE NUMBER