Provider Demographics
NPI:1023454030
Name:HAGEN, FALLON PALMA (PHARMD)
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:PALMA
Last Name: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 1:1109 TERAPIN TRL
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-7811
Mailing Address - Country:US
Mailing Address - Phone:608-931-0932
Mailing Address - Fax:
Practice Address - Street 1:21 S JACKSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548
Practice Address - Country:US
Practice Address - Phone:608-752-7869
Practice Address - Fax:608-752-6806
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15918-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist