Healthcare Provider Details

I. General information

NPI: 1013096429
Provider Name (Legal Business Name): DOUGLAS CALVIN WAGER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 MAIN ST
PENN YAN NY
14527-1219
US

IV. Provider business mailing address

2719 COUNTY HOUSE RD P.O. BOX 607
PENN YAN NY
14527-9314
US

V. Phone/Fax

Practice location:
  • Phone: 315-536-4448
  • Fax: 315-536-5043
Mailing address:
  • Phone: 315-536-4448
  • Fax: 315-536-5043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: