Provider Demographics
NPI:1104372416
Name:WAGNER, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 N RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5401
Mailing Address - Country:US
Mailing Address - Phone:815-578-9710
Mailing Address - Fax:
Practice Address - Street 1:2253 N RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60051-5401
Practice Address - Country:US
Practice Address - Phone:815-578-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.299656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist