Provider Demographics
NPI:1134443559
Name:WAGNER, RICHARD ALAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23631 DANE CT
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4618
Mailing Address - Country:US
Mailing Address - Phone:949-249-9665
Mailing Address - Fax:562-658-3502
Practice Address - Street 1:23631 DANE CT
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4618
Practice Address - Country:US
Practice Address - Phone:949-249-9665
Practice Address - Fax:562-658-3502
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 389871835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist