Provider Demographics
NPI:1760781678
Name:WAGONER, MICHAEL ALLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:WAGONER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:71 MOUNTAINEER DR
Mailing Address - Street 2:HC 71 BOX 1F
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807
Mailing Address - Country:US
Mailing Address - Phone:304-358-2475
Mailing Address - Fax:304-358-3279
Practice Address - Street 1:71 MOUNTAINEER DR
Practice Address - Street 2:HC 71 BOX 1F
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807
Practice Address - Country:US
Practice Address - Phone:304-358-3272
Practice Address - Fax:304-358-3279
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WVRP0005143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist