Provider Demographics
NPI:1700179843
Name:WAGNER, MELINDA SUE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:SUE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-2537
Mailing Address - Country:US
Mailing Address - Phone:419-874-3587
Mailing Address - Fax:419-874-4538
Practice Address - Street 1:1175 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2537
Practice Address - Country:US
Practice Address - Phone:419-874-3587
Practice Address - Fax:419-874-4538
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03219373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist