MEDICARE: TORI D WAGGONER 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	183500000X	Pharmacist	2003029973	MO

General Provider Information

NPI Number	:	1932110483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TORI D WAGGONER PHARMD

Provider Business Mailing Address
First Line	:	12120 LIV 302
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-8210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 HWY 65 NORTH
Second Line	:
City	:	CARROLLTON
State	:	MO
Zip	:	64633
Country	:	US
Telephone Number	:	660-542-1111
Fax Number	:

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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