Provider Demographics
NPI:1932710316
Name:WAGNER, LAUREN ELECTA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ELECTA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 BUXTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-4908
Mailing Address - Country:US
Mailing Address - Phone:904-625-2673
Mailing Address - Fax:
Practice Address - Street 1:2640 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-9107
Practice Address - Country:US
Practice Address - Phone:904-291-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist