MEDICARE: RICHARD WAGONER

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	26001	NC

General Provider Information

NPI Number	:	1912359019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD WAGONER

Provider Business Mailing Address
First Line	:	2937 LOWELL DR
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27217-6071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019 N BREAZEALE AVE
Second Line	:
City	:	MOUNT OLIVE
State	:	NC
Zip	:	28365-1105
Country	:	US
Telephone Number	:	919-658-2554
Fax Number	:

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

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	07/13/2016

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Directions to “ RICHARD WAGONER ” Practice Location

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