Provider Demographics
NPI:1679460778
Name:WAGNER, STEVEN LYLE
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:LYLE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2135
Mailing Address - Country:US
Mailing Address - Phone:618-874-3000
Mailing Address - Fax:618-674-3103
Practice Address - Street 1:1833 KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON PARK
Practice Address - State:IL
Practice Address - Zip Code:62204
Practice Address - Country:US
Practice Address - Phone:618-874-3000
Practice Address - Fax:618-674-3103
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist