Provider Demographics
NPI:1457841546
Name:HAFNER, LARRY DEAN
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:HAFNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SLAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:56172-1312
Mailing Address - Country:US
Mailing Address - Phone:507-836-6159
Mailing Address - Fax:507-836-8753
Practice Address - Street 1:2622 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SLAYTON
Practice Address - State:MN
Practice Address - Zip Code:56172-1312
Practice Address - Country:US
Practice Address - Phone:507-836-6159
Practice Address - Fax:507-836-8753
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist