Provider Demographics
NPI:1457606378
Name:WAGNER, JEREMY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
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:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:MOORCROFT
Mailing Address - State:WY
Mailing Address - Zip Code:82721-0667
Mailing Address - Country:US
Mailing Address - Phone:307-756-2750
Mailing Address - Fax:
Practice Address - Street 1:2000 S DOUGLAS HWY
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5414
Practice Address - Country:US
Practice Address - Phone:307-682-4517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist