Provider Demographics
NPI:1881290765
Name:WANNER, ERIKA JANEMARIE
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:JANEMARIE
Last Name:WANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 KOSER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2671
Mailing Address - Country:US
Mailing Address - Phone:859-552-7910
Mailing Address - Fax:
Practice Address - Street 1:900 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1702
Practice Address - Country:US
Practice Address - Phone:870-763-4507
Practice Address - Fax:870-762-0782
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020993183500000X
TN0000034124183500000X
MSE-010556183500000X
ARC14504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist