Healthcare Provider Details

I. General information

NPI: 1548390115
Provider Name (Legal Business Name): WAGNER INDIAN HEALTH CARE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WASHINGTON AVE NW
WAGNER SD
57380-4300
US

IV. Provider business mailing address

3116 SOLUTIONS CTR
CHICAGO IL
60677-3001
US

V. Phone/Fax

Practice location:
  • Phone: 605-384-3621
  • Fax: 605-384-5229
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number3860
License Number StateSD

VIII. Authorized Official

Name: JAMES CUMMINGS
Title or Position: PHARMACY PROGRAM SPECIALIST
Credential:
Phone: 405-951-6086