Healthcare Provider Details

I. General information

NPI: 1235134388
Provider Name (Legal Business Name): ALLAN HOWARD WAGNER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7635 SOUTHAMPTON TER APT 115
TAMARAC FL
33321-9134
US

IV. Provider business mailing address

15 LINK CT
NEW CITY NY
10956-1623
US

V. Phone/Fax

Practice location:
  • Phone: 347-512-6255
  • Fax: 954-726-2509
Mailing address:
  • Phone: 845-639-6699
  • Fax: 845-639-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS12127
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number022280-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: