Provider Demographics
NPI:1215187455
Name:WAGNER DRUGS INC
Entity Type:Organization
Organization Name:WAGNER DRUGS INC
Other - Org Name:WAGNER'S MOUNT IDA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-867-2812
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-0066
Mailing Address - Country:US
Mailing Address - Phone:870-867-3174
Mailing Address - Fax:
Practice Address - Street 1:744 HIGHWAY 270 E
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-8003
Practice Address - Country:US
Practice Address - Phone:870-867-3174
Practice Address - Fax:870-867-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR159343336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159831OtherPK
AR168721407Medicaid