Healthcare Provider Details

I. General information

NPI: 1356356927
Provider Name (Legal Business Name): WAGNER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N COLLEGE AVE
ALEDO IL
61231-1519
US

IV. Provider business mailing address

108 N COLLEGE AVE
ALEDO IL
61231-1519
US

V. Phone/Fax

Practice location:
  • Phone: 309-582-5678
  • Fax: 309-582-5679
Mailing address:
  • Phone: 309-582-5678
  • Fax: 309-582-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name: GARY R WAGNER
Title or Position: PHARMACIST
Credential: RPH
Phone: 309-582-5678