Provider Demographics
NPI:1932820248
Name:WAGNER, BENJAMIN WILLIAM MARTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM MARTIN
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 1:7732 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1730
Mailing Address - Country:US
Mailing Address - Phone:316-613-9158
Mailing Address - Fax:
Practice Address - Street 1:7739 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2819
Practice Address - Country:US
Practice Address - Phone:913-788-8168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3-107100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist