Provider Demographics
NPI:1033282363
Name:WAGNER, BETH SCHUCKMAN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:SCHUCKMAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 BRITTANY DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8226
Mailing Address - Country:US
Mailing Address - Phone:317-873-4357
Mailing Address - Fax:
Practice Address - Street 1:702 BARNHILL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5128
Practice Address - Country:US
Practice Address - Phone:317-274-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017342A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist