Provider Demographics
NPI:1912580465
Name:WAGNER, SETH ALLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ALLEN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6661
Mailing Address - Country:US
Mailing Address - Phone:636-379-1918
Mailing Address - Fax:
Practice Address - Street 1:1749 WOODSTONE DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7404
Practice Address - Country:US
Practice Address - Phone:636-447-1229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297649183500000X
MO2016007951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist