Provider Demographics
NPI:1952947640
Name:WAGNER, VERONICA ELLENMARIE
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:ELLENMARIE
Last Name:WAGNER
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 1:1402 PIEDMONT DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-0273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2190 GILMER AVE
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-7123
Practice Address - Country:US
Practice Address - Phone:334-283-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist