MEDICARE: LARRY D. WAGENKNECHT R.PH.

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	5302024102	MI

General Provider Information

NPI Number	:	1790856995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY D. WAGENKNECHT R.PH.

Provider Business Mailing Address
First Line	:	6097 PARTRIDGE ST
Second Line	:
City	:	HASLETT
State	:	MI
Zip	:	48840-8986
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 N WASHINGTON AVE
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48906-5166
Country	:	US
Telephone Number	:	517-377-0226
Fax Number	:

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

Provider Enumeration Date	:	11/11/2006
Last Update Date	:	07/08/2007

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