Provider Demographics
NPI:1790816072
Name:VAN WAGENEN, SIMON B (RPH)
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:B
Last Name:VAN WAGENEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:15604 SW 161ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKER
Mailing Address - State:FL
Mailing Address - Zip Code:32622-2540
Mailing Address - Country:US
Mailing Address - Phone:904-449-3937
Mailing Address - Fax:904-964-5315
Practice Address - Street 1:470 W MADISON ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3926
Practice Address - Country:US
Practice Address - Phone:904-964-6759
Practice Address - Fax:904-964-5315
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS16532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist