Healthcare Provider Details

I. General information

NPI: 1821584830
Provider Name (Legal Business Name): ANDREW J WAGNER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W BROADWAY ST
EAGLE GROVE IA
50533-1711
US

IV. Provider business mailing address

1409 SW 1ST ST
EAGLE GROVE IA
50533-1910
US

V. Phone/Fax

Practice location:
  • Phone: 515-448-3814
  • Fax:
Mailing address:
  • Phone: 515-851-2421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number23170
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: