Provider Demographics
NPI:1780040212
Name:HAGSTROM, JEFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HAGSTROM
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 1:100 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-1990
Mailing Address - Country:US
Mailing Address - Phone:203-888-4567
Mailing Address - Fax:
Practice Address - Street 1:100 OXFORD RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:CT
Practice Address - Zip Code:06478-1990
Practice Address - Country:US
Practice Address - Phone:203-888-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0006341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist