Provider Demographics
NPI:1306393046
Name:WAGNER, RICHARD ALFRED
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALFRED
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 ISLETA BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4633
Mailing Address - Country:US
Mailing Address - Phone:505-877-1620
Mailing Address - Fax:505-877-3309
Practice Address - Street 1:1643 ISLETA BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4633
Practice Address - Country:US
Practice Address - Phone:505-877-1620
Practice Address - Fax:505-877-3309
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist