Provider Demographics
NPI:1568139384
Name:HAGEN, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4352
Mailing Address - Country:US
Mailing Address - Phone:209-526-4773
Mailing Address - Fax:
Practice Address - Street 1:1707 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4352
Practice Address - Country:US
Practice Address - Phone:209-526-4773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1607371183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician