Provider Demographics
NPI:1043597719
Name:COLAIANNI-WAGNER, BARBAR AMALIA
Entity Type:Individual
Prefix:
First Name:BARBAR
Middle Name:AMALIA
Last Name:COLAIANNI-WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:
Other - Last Name:COLAIANNI-WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACY
Mailing Address - Street 1:300 E HILL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6155
Mailing Address - Country:US
Mailing Address - Phone:702-275-9011
Mailing Address - Fax:
Practice Address - Street 1:1870 E HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4955
Practice Address - Country:US
Practice Address - Phone:702-275-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist