Provider Demographics
NPI:1750633244
Name:VAN DER HAGEN, RACHEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:
Last Name:VAN DER HAGEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 POINTE PARKWAY BLVD APT 4106
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0654
Mailing Address - Country:US
Mailing Address - Phone:918-381-4426
Mailing Address - Fax:
Practice Address - Street 1:112 E STATE HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4402
Practice Address - Country:US
Practice Address - Phone:405-376-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist