Provider Demographics
NPI:1821431206
Name:HAGEN, LANELL
Entity Type:Individual
Prefix:
First Name:LANELL
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 1:2800 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1420
Mailing Address - Country:US
Mailing Address - Phone:701-293-0221
Mailing Address - Fax:
Practice Address - Street 1:2800 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1420
Practice Address - Country:US
Practice Address - Phone:701-293-0221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist