Provider Demographics
NPI:1578026423
Name:WAGNER, DENISE JEAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:JEAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 ELMORE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3513
Mailing Address - Country:US
Mailing Address - Phone:563-359-4874
Mailing Address - Fax:
Practice Address - Street 1:5811 ELMORE AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3513
Practice Address - Country:US
Practice Address - Phone:563-359-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist