Provider Demographics
NPI:1699361204
Name:HAGEDORN, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HAGEDORN
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 1:7121 S CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FERDINAND
Mailing Address - State:IN
Mailing Address - Zip Code:47532
Mailing Address - Country:US
Mailing Address - Phone:812-661-7749
Mailing Address - Fax:
Practice Address - Street 1:20 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:FERDINAND
Practice Address - State:IN
Practice Address - Zip Code:47532-9665
Practice Address - Country:US
Practice Address - Phone:812-367-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026576A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist