MEDICARE: WAGENER DRUG CO INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	6210	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2088208	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144362229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGENER DRUG CO INC

Provider Business Mailing Address
First Line	:	PO BOX 129
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164-0129
Country	:	US
Telephone Number	:	803-564-5381
Fax Number	:	803-564-5398

Provider Business Practice Location Address
First Line	:	129 N MAIN ST
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164
Country	:	US
Telephone Number	:	803-564-5381
Fax Number	:	803-564-5398

Authorized Official
Title or Position	:	OWNER
Name	:	THERESA DYCHES
Credential	:
Telephone Number	:	803-564-5381

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	06/25/2013

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Directions to “WAGENER DRUG CO INC ” Practice Location

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