=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760819015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM TODD WAGGONER RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2013
-----------------------------------------------------
Last Update Date | 10/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 HIGHWAY 31 NORTH
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-233-0181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 238 BROCKTON DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35756-4048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-653-3463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12292
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------