Provider Demographics
NPI:1023223989
Name:WIGGERS, STEVEN R (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:R
Last Name:WIGGERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-0777
Mailing Address - Country:US
Mailing Address - Phone:330-274-2209
Mailing Address - Fax:330-274-5220
Practice Address - Street 1:10870 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255-0777
Practice Address - Country:US
Practice Address - Phone:330-274-2209
Practice Address - Fax:330-274-5220
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03311734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5492800Medicaid
OH5492800Medicaid