Provider Demographics
NPI:1841776739
Name:WAGNER, ZACH
Entity Type:Individual
Prefix:
First Name:ZACH
Middle Name:
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 1:1301 SAVOY PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-9457
Mailing Address - Country:US
Mailing Address - Phone:217-373-0702
Mailing Address - Fax:
Practice Address - Street 1:1301 SAVOY PLAZA LN
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-9457
Practice Address - Country:US
Practice Address - Phone:217-373-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist