Provider Demographics
NPI:1619195542
Name:WAGNER, CHARLOTTE ERIN (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ERIN
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 1:2469 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5119
Mailing Address - Country:US
Mailing Address - Phone:801-475-0378
Mailing Address - Fax:
Practice Address - Street 1:2469 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5119
Practice Address - Country:US
Practice Address - Phone:801-475-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322438-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist