Provider Demographics
NPI:1891003067
Name:VAN WAGENEN, ELONA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELONA
Middle Name:
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 MCMAHON BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5010
Mailing Address - Country:US
Mailing Address - Phone:505-922-4303
Mailing Address - Fax:505-922-4313
Practice Address - Street 1:4800 MCMAHON BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5010
Practice Address - Country:US
Practice Address - Phone:505-922-4303
Practice Address - Fax:505-922-4313
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist