Provider Demographics
NPI:1366623555
Name:WAGNER, NORMA LINDA (RPH)
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:LINDA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 SOUTH RT 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544
Mailing Address - Country:US
Mailing Address - Phone:815-577-2616
Mailing Address - Fax:815-577-2618
Practice Address - Street 1:13460 S RTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5270
Practice Address - Country:US
Practice Address - Phone:815-577-2616
Practice Address - Fax:815-577-2618
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510407901835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy