Provider Demographics
NPI:1881151876
Name:WAGNER, JEFFREY FRANK (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:FRANK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 HEALTH PARK WAY STE 130
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5177
Mailing Address - Country:US
Mailing Address - Phone:941-907-1500
Mailing Address - Fax:941-907-1544
Practice Address - Street 1:6310 HEALTH PARK WAY STE 130
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5177
Practice Address - Country:US
Practice Address - Phone:941-907-1500
Practice Address - Fax:941-907-1544
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist