Provider Demographics
NPI:1891007068
Name:WACKOWSKI, ANGELA REE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:REE
Last Name:WACKOWSKI
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 1:130 W RAVINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3837
Mailing Address - Country:US
Mailing Address - Phone:423-224-6860
Mailing Address - Fax:423-224-5657
Practice Address - Street 1:130 W RAVINE RD STE 101
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-6860
Practice Address - Fax:423-224-5657
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16086183500000X
TN13012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist