Provider Demographics
NPI:1417232901
Name:HANSEN, BETH (RPH)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 BUNKER LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-754-6409
Mailing Address - Fax:763-754-6478
Practice Address - Street 1:2134 BUNKER LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3910
Practice Address - Country:US
Practice Address - Phone:763-754-6409
Practice Address - Fax:763-754-6478
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist