Healthcare Provider Details

I. General information

NPI: 1033282363
Provider Name (Legal Business Name): BETH SCHUCKMAN WAGNER RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BARNHILL DR
INDIANAPOLIS IN
46202-5128
US

IV. Provider business mailing address

4371 BRITTANY DR
ZIONSVILLE IN
46077-8226
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-2335
  • Fax:
Mailing address:
  • Phone: 317-873-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26017342A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: