Provider Demographics
NPI:1609216019
Name:HAGEN, DAN JOHN (RPH)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:JOHN
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 1:808 LAKE ST S
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2614
Mailing Address - Country:US
Mailing Address - Phone:651-464-5518
Mailing Address - Fax:651-464-1513
Practice Address - Street 1:808 LAKE ST S
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2614
Practice Address - Country:US
Practice Address - Phone:651-464-5518
Practice Address - Fax:651-464-1513
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist