Healthcare Provider Details

I. General information

NPI: 1992161491
Provider Name (Legal Business Name): AUDREY WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W BURNSIDE ST
PORTLAND OR
97209-3514
US

IV. Provider business mailing address

232 NW 6TH AVE
PORTLAND OR
97209-3609
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-4533
  • Fax:
Mailing address:
  • Phone: 503-294-1681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH0013676
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: