Provider Demographics
NPI:1164044269
Name:RENFRO, SAMANTHA (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RENFRO
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10205 GREENBRIER RD APT 304
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3424
Mailing Address - Country:US
Mailing Address - Phone:952-356-7395
Mailing Address - Fax:
Practice Address - Street 1:2021 MARKET DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7546
Practice Address - Country:US
Practice Address - Phone:651-439-0992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20188-40183500000X
MN214616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist