Provider Demographics
NPI:1881731073
Name:WAGNERS PHARMACY INC
Entity type:Organization
Organization Name:WAGNERS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-426-1788
Mailing Address - Street 1:3113 S. 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214
Mailing Address - Country:US
Mailing Address - Phone:502-375-3800
Mailing Address - Fax:502-375-0085
Practice Address - Street 1:3113 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214
Practice Address - Country:US
Practice Address - Phone:502-375-3800
Practice Address - Fax:502-375-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
KYP008513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54004643Medicaid
KY54004643Medicaid