Provider Demographics
NPI:1437419744
Name:HAGEMANN, DIANE MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:HAGEMANN
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 1:15011 WOODLAND TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62615-9429
Mailing Address - Country:US
Mailing Address - Phone:217-438-9226
Mailing Address - Fax:
Practice Address - Street 1:15011 WOODLAND TRAIL DRIVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615
Practice Address - Country:US
Practice Address - Phone:217-438-9226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051041061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist