Provider Demographics
NPI:1184100398
Name:KETTERLING, SAMANTHA ANN (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:KETTERLING
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANN
Other - Last Name:SORENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1220 55TH AVE S APT 309
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-9271
Mailing Address - Country:US
Mailing Address - Phone:218-790-0492
Mailing Address - Fax:
Practice Address - Street 1:2475 32ND AVE S STE 1
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3606
Practice Address - Country:US
Practice Address - Phone:701-775-4209
Practice Address - Fax:701-775-9122
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist