Provider Demographics
NPI:1619511623
Name:WAGNER, ANDREW (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 VALLEY HI DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-4602
Mailing Address - Country:US
Mailing Address - Phone:210-674-3710
Mailing Address - Fax:
Practice Address - Street 1:302 VALLEY HI DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-4602
Practice Address - Country:US
Practice Address - Phone:210-674-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist