Provider Demographics
NPI:1841514593
Name:WAGNER, SCOTT DAVIS
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVIS
Last Name:WAGNER
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 1:125 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7261
Mailing Address - Country:US
Mailing Address - Phone:570-687-8503
Mailing Address - Fax:
Practice Address - Street 1:25059 STATE ROUTE 11
Practice Address - Street 2:HALLSTEAD PLAZA
Practice Address - City:HALLSTEAD
Practice Address - State:PA
Practice Address - Zip Code:18822-8831
Practice Address - Country:US
Practice Address - Phone:570-879-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040460L183500000X
NY053425-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist