Provider Demographics
NPI:1700296472
Name:WAGONBLOTT, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAGONBLOTT
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 1:7749 BURKEY DR
Mailing Address - Street 2:8000 E BROAD STREET
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2619
Mailing Address - Country:US
Mailing Address - Phone:614-322-7433
Mailing Address - Fax:614-322-7465
Practice Address - Street 1:8000 E BROAD ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8032
Practice Address - Country:US
Practice Address - Phone:614-322-7433
Practice Address - Fax:614-322-7433
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH032092781835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy