Provider Demographics
NPI:1497035539
Name:WAGNER, DAREN (RPH)
Entity Type:Individual
Prefix:
First Name:DAREN
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 1:411 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2630
Mailing Address - Country:US
Mailing Address - Phone:208-882-0900
Mailing Address - Fax:208-883-1407
Practice Address - Street 1:411 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2630
Practice Address - Country:US
Practice Address - Phone:208-882-0900
Practice Address - Fax:208-883-1407
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist