Provider Demographics
NPI:1073339388
Name:WAGNER, MARY LOUISE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
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 1:12 DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-2109
Mailing Address - Country:US
Mailing Address - Phone:732-439-0282
Mailing Address - Fax:
Practice Address - Street 1:18 CENTRE DR
Practice Address - Street 2:
Practice Address - City:MONROE TWP
Practice Address - State:NJ
Practice Address - Zip Code:08831-1501
Practice Address - Country:US
Practice Address - Phone:732-439-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJA-3976380171400000X
NJ28RJ101561835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No171400000XOther Service ProvidersHealth & Wellness Coach