Provider Demographics
NPI:1245647700
Name:WAGNER, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WAGNER
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 1:1650 W MALONEY AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-3305
Mailing Address - Country:US
Mailing Address - Phone:505-722-3823
Mailing Address - Fax:
Practice Address - Street 1:1650 W MALONEY AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-3305
Practice Address - Country:US
Practice Address - Phone:505-722-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007923183500000X
NV13889183500000X
IA18855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist