Healthcare Provider Details

I. General information

NPI: 1346734563
Provider Name (Legal Business Name): ERIN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 W 2ND ST
KINGSLEY IA
51028-7751
US

IV. Provider business mailing address

5316 E POP FLY PL
SIOUX FALLS SD
57110-4700
US

V. Phone/Fax

Practice location:
  • Phone: 712-378-2700
  • Fax:
Mailing address:
  • Phone: 605-759-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6567
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: