Provider Demographics
NPI:1982276366
Name:WAGNER, GARRISON SCOTT (PHARMD)
Entity Type:Individual
Prefix:
First Name:GARRISON
Middle Name:SCOTT
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 1:817 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1240
Mailing Address - Country:US
Mailing Address - Phone:127-052-7937
Mailing Address - Fax:
Practice Address - Street 1:817 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1240
Practice Address - Country:US
Practice Address - Phone:270-527-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist