Provider Demographics
NPI:1235276973
Name:HAGEN, BRYAN P (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:P
Last Name:HAGEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31341 297TH ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1435
Mailing Address - Country:US
Mailing Address - Phone:507-376-3867
Mailing Address - Fax:507-376-5441
Practice Address - Street 1:426 10TH ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2341
Practice Address - Country:US
Practice Address - Phone:507-376-3444
Practice Address - Fax:507-376-5441
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115021-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist