Provider Demographics
NPI:1063785715
Name:WAGNER, REGINA E (RPH)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7342 W FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-3600
Mailing Address - Country:US
Mailing Address - Phone:773-775-3777
Mailing Address - Fax:773-775-6867
Practice Address - Street 1:7342 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-3600
Practice Address - Country:US
Practice Address - Phone:773-775-3777
Practice Address - Fax:773-775-6867
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist