Provider Demographics
NPI:1235134388
Name:WAGNER, ALLAN HOWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:HOWARD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LINK CT
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-1623
Mailing Address - Country:US
Mailing Address - Phone:845-639-6699
Mailing Address - Fax:845-639-6699
Practice Address - Street 1:7635 SOUTHAMPTON TER
Practice Address - Street 2:APT 115
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-9134
Practice Address - Country:US
Practice Address - Phone:347-512-6255
Practice Address - Fax:954-726-2509
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS12127183500000X
NY022280-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist