Provider Demographics
NPI:1982817961
Name:WAGNER, MEREDITH (PHARM D)
Entity Type:Individual
Prefix:MS
First Name:MEREDITH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5573
Mailing Address - Country:US
Mailing Address - Phone:601-630-4003
Mailing Address - Fax:
Practice Address - Street 1:3408 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5573
Practice Address - Country:US
Practice Address - Phone:601-630-4003
Practice Address - Fax:601-630-4004
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE099501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist