Provider Demographics
NPI:1831516509
Name:WAGNER, MERCEDES FAJARDO (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:MERCEDES
Middle Name:FAJARDO
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23631 DANE CT
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4618
Mailing Address - Country:US
Mailing Address - Phone:949-249-9665
Mailing Address - Fax:949-149-9665
Practice Address - Street 1:23631 DANE CT
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4618
Practice Address - Country:US
Practice Address - Phone:949-249-9665
Practice Address - Fax:949-249-9665
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist