Provider Demographics
NPI:1114016235
Name:WAGNERS PHARMACY
Entity Type:Organization
Organization Name:WAGNERS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:502-375-3800
Mailing Address - Street 1:3113 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1710
Mailing Address - Country:US
Mailing Address - Phone:502-375-3800
Mailing Address - Fax:502-375-0085
Practice Address - Street 1:3113 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1710
Practice Address - Country:US
Practice Address - Phone:502-375-3800
Practice Address - Fax:502-375-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty