Provider Demographics
NPI:1629515747
Name:WAGNER, HARRY (RPH)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:WAGNER
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 1:505 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-5601
Mailing Address - Country:US
Mailing Address - Phone:785-213-6089
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-8780
Practice Address - Country:US
Practice Address - Phone:785-213-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-12219183500000X
NV8125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist