Provider Demographics
NPI:1235524075
Name:WAGNER, JOHN HERBERT (R PH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:HERBERT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3544
Mailing Address - Country:US
Mailing Address - Phone:262-639-1611
Mailing Address - Fax:262-639-5611
Practice Address - Street 1:3900 ERIE ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3544
Practice Address - Country:US
Practice Address - Phone:262-639-1611
Practice Address - Fax:262-639-5611
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8002-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1225062441OtherNPI