Provider Demographics
NPI:1407456874
Name:WAGNON, RACHEL (PHARM D)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:WAGNON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2137
Mailing Address - Country:US
Mailing Address - Phone:405-577-0051
Mailing Address - Fax:405-577-0053
Practice Address - Street 1:1001 E MAIN ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2137
Practice Address - Country:US
Practice Address - Phone:405-577-0051
Practice Address - Fax:405-577-0053
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist