Provider Demographics
NPI:1609192053
Name:VANWAGNER, L. CLIFFORD (RPH)
Entity Type:Individual
Prefix:MR
First Name:L.
Middle Name:CLIFFORD
Last Name:VANWAGNER
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 1:131 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1346
Mailing Address - Country:US
Mailing Address - Phone:518-691-1462
Mailing Address - Fax:518-691-1640
Practice Address - Street 1:131 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1346
Practice Address - Country:US
Practice Address - Phone:518-691-1462
Practice Address - Fax:518-691-1640
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist