Provider Demographics
NPI:1306051305
Name:WAGEMANN, BLAIR SUZANNE (PD)
Entity type:Individual
Prefix:MS
First Name:BLAIR
Middle Name:SUZANNE
Last Name:WAGEMANN
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13240 N OLD WIRE RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-9885
Mailing Address - Country:US
Mailing Address - Phone:479-451-0413
Mailing Address - Fax:479-451-0413
Practice Address - Street 1:153 E MONTE PAINTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4002
Practice Address - Country:US
Practice Address - Phone:479-444-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR007777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist