Healthcare Provider Details

I. General information

NPI: 1720193063
Provider Name (Legal Business Name): DEBBIE LYNN WAGGONER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W 7TH ST SLOT 119
LITTLE ROCK AR
72205-5446
US

IV. Provider business mailing address

350 RED OAK AIRPARK
CABOT AR
72023-8512
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-6330
  • Fax: 501-257-6329
Mailing address:
  • Phone: 501-257-6330
  • Fax: 501-257-6329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number8910
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: