Healthcare Provider Details

I. General information

NPI: 1679131759
Provider Name (Legal Business Name): SHELBY WAGNER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 N MAIN ST
MITCHELL SD
57301-1017
US

IV. Provider business mailing address

2701 S MINNESOTA AVE STE 1
SIOUX FALLS SD
57105-4746
US

V. Phone/Fax

Practice location:
  • Phone: 605-292-1013
  • Fax:
Mailing address:
  • Phone: 605-367-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6652
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: