Provider Demographics
NPI:1528060563
Name:HAGMANN, BRUCE D (R,PH, MSC,)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:HAGMANN
Suffix:
Gender:M
Credentials:R,PH, MSC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76932-0220
Mailing Address - Country:US
Mailing Address - Phone:325-884-2579
Mailing Address - Fax:325-884-3234
Practice Address - Street 1:903 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:TX
Practice Address - Zip Code:76932-3201
Practice Address - Country:US
Practice Address - Phone:325-884-3300
Practice Address - Fax:325-884-3234
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144632Medicaid
TX144632Medicaid