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NPI Code Detail

MEDICARE: DR. ELLEN WANDA WAGNER PHARM D

MEDICARE: DR. ELLEN WANDA WAGNER PHARM D
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
1183500000XPharmacist12235TN

General Provider Information

NPI Number : 1821300823
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ELLEN WANDA WAGNER PHARM D
Provider Business Mailing Address
First Line : 5006 N BROADWAY ST
Second Line :
City : KNOXVILLE
State : TN
Zip : 37918-2340
Country : US
Telephone Number : 865-688-1812
Fax Number :
Provider Business Practice Location Address
First Line : 5006 N BROADWAY ST
Second Line :
City : KNOXVILLE
State : TN
Zip : 37918-2340
Country : US
Telephone Number : 865-688-1812
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2010
Last Update Date : 07/07/2010

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