Provider Demographics
NPI:1801169933
Name:WAGNER, ROSS M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:M
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 1:36 JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07422-1034
Mailing Address - Country:US
Mailing Address - Phone:973-387-5322
Mailing Address - Fax:973-875-0529
Practice Address - Street 1:38-42 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:NJ
Practice Address - Zip Code:07461-2331
Practice Address - Country:US
Practice Address - Phone:973-875-4141
Practice Address - Fax:973-875-0529
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03295300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist