Provider Demographics
NPI:1326359423
Name:WAGNER, RICHARD ROSS (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROSS
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 1:3282 BETHEL RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5603
Mailing Address - Country:US
Mailing Address - Phone:360-876-0969
Mailing Address - Fax:360-876-9114
Practice Address - Street 1:3282 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5603
Practice Address - Country:US
Practice Address - Phone:360-876-0969
Practice Address - Fax:360-876-9114
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00009108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist