Provider Demographics
NPI:1134569585
Name:O'HAGAN, TIFFANY M (PHARM D)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:O'HAGAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:M
Other - Last Name:POTRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:950 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6175
Mailing Address - Country:US
Mailing Address - Phone:920-303-1712
Mailing Address - Fax:
Practice Address - Street 1:192 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3462
Practice Address - Country:US
Practice Address - Phone:920-921-5264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-30
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17039-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist