Provider Demographics
NPI:1811095748
Name:WAGNE, KACY LAMAR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KACY
Middle Name:LAMAR
Last Name:WAGNE
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 1:6914 SIR PALLEAS
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5283 OLD BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-3908
Practice Address - Country:US
Practice Address - Phone:361-806-5612
Practice Address - Fax:361-806-5616
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist