Provider Demographics
NPI:1912359019
Name:WAGONER, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WAGONER
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 1:2937 LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-6071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 N BREAZEALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1105
Practice Address - Country:US
Practice Address - Phone:919-658-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist