MEDICARE: DR. MATTHEW JAMES WAGNER PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051289635	IL

General Provider Information

NPI Number	:	1316140312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW JAMES WAGNER PHARMD

Provider Business Mailing Address
First Line	:	9357 S CLAREMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-6219
Country	:	US
Telephone Number	:	708-476-7149
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 CHICAGO RD
Second Line	:
City	:	SOUTH CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-5421
Country	:	US
Telephone Number	:	708-756-7775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	12/14/2012

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