Healthcare Provider Details

I. General information

NPI: 1306393046
Provider Name (Legal Business Name): RICHARD ALFRED WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 ISLETA BLVD SW
ALBUQUERQUE NM
87105-4633
US

IV. Provider business mailing address

1643 ISLETA BLVD SW
ALBUQUERQUE NM
87105-4633
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-1620
  • Fax: 505-877-3309
Mailing address:
  • Phone: 505-877-1620
  • Fax: 505-877-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00005604
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: