Provider Demographics
NPI:1891807111
Name:WAGNER, RICHARD MARVIN (RPH02)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MARVIN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RPH02
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 PARK FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6919
Mailing Address - Country:US
Mailing Address - Phone:352-735-4765
Mailing Address - Fax:353-735-4765
Practice Address - Street 1:450 E BURLEIGH BLVD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5257
Practice Address - Country:US
Practice Address - Phone:352-343-6436
Practice Address - Fax:352-343-7064
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0029657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist