Provider Demographics
NPI:1558644484
Name:WAGNER, MICHELLE LEE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
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 1:6485 WILMINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7110
Mailing Address - Country:US
Mailing Address - Phone:937-433-5314
Mailing Address - Fax:937-433-7437
Practice Address - Street 1:6485 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-7110
Practice Address - Country:US
Practice Address - Phone:937-433-5314
Practice Address - Fax:937-433-7437
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-20428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist