Healthcare Provider Details

I. General information

NPI: 1881310282
Provider Name (Legal Business Name): HAZEN HEALTH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MAIN ST W
HAZEN ND
58545-4205
US

IV. Provider business mailing address

PO BOX 669
HAZEN ND
58545-0669
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2312
  • Fax: 701-748-2637
Mailing address:
  • Phone: 701-748-2312
  • Fax: 701-748-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: WYATT ELDON MARTENSON
Title or Position: OWNER/PRESIDENT
Credential: PHARMD
Phone: 701-873-5215