Healthcare Provider Details

I. General information

NPI: 1619326881
Provider Name (Legal Business Name): WAGNER DRUGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 HWY 270 EAST
MOUNT IDA AR
71957
US

IV. Provider business mailing address

PO BOX 66
MOUNT IDA AR
71957-0066
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-2812
  • Fax: 870-867-2033
Mailing address:
  • Phone: 479-243-6169
  • Fax: 870-867-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberAR15934
License Number StateAR

VIII. Authorized Official

Name: LAURA LYNN WAGNER
Title or Position: OWNER
Credential:
Phone: 870-867-2812