Provider Demographics
NPI:1457723835
Name:WAGENER, RYAN MATTHEW (RPH)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:WAGENER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 SPA RD
Mailing Address - Street 2:APT 203
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-1037
Mailing Address - Country:US
Mailing Address - Phone:410-718-7198
Mailing Address - Fax:
Practice Address - Street 1:2601 RIVA RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7304
Practice Address - Country:US
Practice Address - Phone:410-571-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist