Provider Demographics
NPI:1962008631
Name:WAGNER, GREGORY MARK (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 DIFFLEY RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1777
Mailing Address - Country:US
Mailing Address - Phone:651-452-5500
Mailing Address - Fax:
Practice Address - Street 1:1020 DIFFLEY RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1777
Practice Address - Country:US
Practice Address - Phone:651-452-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist