Healthcare Provider Details

I. General information

NPI: 1861304065
Provider Name (Legal Business Name): HAYDEN BUTZLAFF
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 12TH ST SW
FOREST LAKE MN
55025-1749
US

IV. Provider business mailing address

1501 PARK ST
WHITE BEAR LAKE MN
55110-7702
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-1994
  • Fax:
Mailing address:
  • Phone: 651-583-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number127552
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: