MEDICARE: KATHRYN WAGENBACH PHARMD, RPH

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	63413	CA

General Provider Information

NPI Number	:	1477839868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN WAGENBACH PHARMD, RPH

Provider Business Mailing Address
First Line	:	140 W LOS ANGELES AVE
Second Line	:
City	:	MOORPARK
State	:	CA
Zip	:	93021-1897
Country	:	US
Telephone Number	:	805-529-9601
Fax Number	:	805-529-9607

Provider Business Practice Location Address
First Line	:	140 W LOS ANGELES AVE
Second Line	:
City	:	MOORPARK
State	:	CA
Zip	:	93021-1897
Country	:	US
Telephone Number	:	805-529-9601
Fax Number	:	805-529-9607

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

Provider Enumeration Date	:	10/29/2011
Last Update Date	:	10/29/2011

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