Provider Demographics
NPI:1821384728
Name:WAGNER, JOHN C (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:1703 ELM ST W
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924
Mailing Address - Country:US
Mailing Address - Phone:803-943-0983
Mailing Address - Fax:803-943-0783
Practice Address - Street 1:1703 ELM ST W
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924
Practice Address - Country:US
Practice Address - Phone:803-943-0983
Practice Address - Fax:803-943-0783
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023891183500000X
SC11713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist