MEDICARE: ELLEN WAGNER RPH

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	183500000X	Pharmacist	03314370	OH

General Provider Information

NPI Number	:	1417349036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN WAGNER RPH

Provider Business Mailing Address
First Line	:	5420 LIBERTY FAIRFIELD RD
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-2680
Country	:	US
Telephone Number	:	513-785-7920
Fax Number	:	513-785-7921

Provider Business Practice Location Address
First Line	:	5420 LIBERTY FAIRFIELD RD
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-2680
Country	:	US
Telephone Number	:	513-785-7920
Fax Number	:	513-785-7921

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

Provider Enumeration Date	:	02/19/2015
Last Update Date	:	02/19/2015

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