Provider Demographics
NPI:1295016491
Name:WAGNER, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 OAK POINT DR
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321
Mailing Address - Country:US
Mailing Address - Phone:419-307-0697
Mailing Address - Fax:
Practice Address - Street 1:6701 FRANK AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7268
Practice Address - Country:US
Practice Address - Phone:330-497-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03129568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist