Provider Demographics
NPI:1356649974
Name:WAGNER, TODD (RPH)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
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 1:4408 W HUNDRED RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1738
Mailing Address - Country:US
Mailing Address - Phone:804-748-2284
Mailing Address - Fax:
Practice Address - Street 1:4408 W HUNDRED RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1738
Practice Address - Country:US
Practice Address - Phone:804-748-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-06
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009456183500000X
NC11668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist