Healthcare Provider Details

I. General information

NPI: 1790610624
Provider Name (Legal Business Name): TYLER J HAUGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

3520 EAGLE RUN DR
WEST FARGO ND
58078-8198
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5727
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: