MEDICARE: DR. MARY LOUISE WAGNER PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach	A-3976380	NJ
2	1835P2201X	Ambulatory Care Pharmacist	28RJ10156	NJ

General Provider Information

NPI Number	:	1073339388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY LOUISE WAGNER PHARMD

Provider Business Mailing Address
First Line	:	12 DOROTHY LN
Second Line	:
City	:	MILLTOWN
State	:	NJ
Zip	:	08850-2109
Country	:	US
Telephone Number	:	732-439-0282
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 CENTRE DR
Second Line	:
City	:	MONROE TWP
State	:	NJ
Zip	:	08831-1501
Country	:	US
Telephone Number	:	732-439-0282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2024
Last Update Date	:	12/02/2024

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