Provider Demographics
NPI:1477379220
Name:KNUDSON, SAMANTHA JO
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:KNUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56515-4113
Mailing Address - Country:US
Mailing Address - Phone:218-770-8906
Mailing Address - Fax:
Practice Address - Street 1:712 S CASCADE ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2913
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8787
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6610183500000X
MN126715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist