Provider Demographics
NPI:1255891578
Name:WAGNER, LAURA LYNN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-0066
Mailing Address - Country:US
Mailing Address - Phone:870-867-3174
Mailing Address - Fax:870-867-2033
Practice Address - Street 1:744 HWY 270 EAST
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957
Practice Address - Country:US
Practice Address - Phone:870-867-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR08356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist