Provider Demographics
NPI:1114264082
Name:WAGNER, REBECCA MARY (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 TUSCAN WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1831
Mailing Address - Country:US
Mailing Address - Phone:904-940-2894
Mailing Address - Fax:904-940-2899
Practice Address - Street 1:84 TUSCAN WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-1831
Practice Address - Country:US
Practice Address - Phone:904-940-2894
Practice Address - Fax:904-940-2899
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist