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General NPI Number Information
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NPI Number | 1366712879
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Entity Type | Individual
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Provider Name | CHRISTOPHER CHAD WAGONER
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Gender | Male
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Dates
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Enumeration Date | 01/01/2012
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Last Update Date | 01/01/2012
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Provider Practice Location Address
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Address Line | 722 W INDEPENDENCE BLVD
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City | MOUNT AIRY
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State | NC
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Zip | 27030-3574
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Country | US
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Telephone | 336-789-9006
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Fax | 336-789-0537
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Provider Business Mailing Address
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Address Line | 722 W INDEPENDENCE BLVD
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City | MOUNT AIRY
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State | NC
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Zip | 27030-3574
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Country | US
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Telephone | 336-789-9006
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Fax | 336-789-0537
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 12706
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License Number State | NC
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