Provider Demographics
NPI:1144668104
Name:WAHLSTROM, JENNA M (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:WAHLSTROM
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 1:244 N MAIN ST
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7124
Mailing Address - Country:US
Mailing Address - Phone:701-444-2410
Mailing Address - Fax:701-444-2921
Practice Address - Street 1:244 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7124
Practice Address - Country:US
Practice Address - Phone:701-444-2410
Practice Address - Fax:701-444-2921
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist