Provider Demographics
NPI:1548390115
Name:WAGNER INDIAN HEALTH CARE PHARMACY
Entity Type:Organization
Organization Name:WAGNER INDIAN HEALTH CARE PHARMACY
Other - Org Name:WAGNER INDIAN HEALTH CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-951-6086
Mailing Address - Street 1:3116 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 WASHINGTON AVE NW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-4300
Practice Address - Country:US
Practice Address - Phone:605-384-3621
Practice Address - Fax:605-384-5229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3860332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4304844OtherNCPDP PROVIDER IDENTIFICATION NUMBER
SDSD5540030Medicaid