Provider Demographics
NPI:1033705363
Name:WAGONER, MATTHEW DARBY (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DARBY
Last Name:WAGONER
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 1:511 N HEWITT DR STE 1
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-3093
Mailing Address - Country:US
Mailing Address - Phone:254-733-3089
Mailing Address - Fax:
Practice Address - Street 1:511 N HEWITT DR STE 1
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3093
Practice Address - Country:US
Practice Address - Phone:254-666-5000
Practice Address - Fax:254-666-5002
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist