Healthcare Provider Details

I. General information

NPI: 1326359423
Provider Name (Legal Business Name): RICHARD ROSS WAGNER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3282 BETHEL RD SE
PORT ORCHARD WA
98366-5603
US

IV. Provider business mailing address

3282 BETHEL RD SE
PORT ORCHARD WA
98366-5603
US

V. Phone/Fax

Practice location:
  • Phone: 360-876-0969
  • Fax: 360-876-9114
Mailing address:
  • Phone: 360-876-0969
  • Fax: 360-876-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00009108
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: