MEDICARE: WAGNER DRUGS 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	3336L0003X	Long Term Care Pharmacy	AR15934	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2159831	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215187455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNER DRUGS INC

Provider Business Mailing Address
First Line	:	PO BOX 66
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-0066
Country	:	US
Telephone Number	:	870-867-3174
Fax Number	:

Provider Business Practice Location Address
First Line	:	744 HIGHWAY 270 E
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-8003
Country	:	US
Telephone Number	:	870-867-3174
Fax Number	:	870-867-2033

Authorized Official
Title or Position	:	OWNER
Name	:	LAURA WAGNER
Credential	:
Telephone Number	:	870-867-2812

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	06/01/2016

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