Provider Demographics
NPI:1518399054
Name:WAGNER, REBECCA (RPH, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45715-0697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 DIETZ LANE
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:OH
Practice Address - Zip Code:45715
Practice Address - Country:US
Practice Address - Phone:740-984-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH032328232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist