Provider Demographics
NPI:1366427924
Name:WAGNER, RICHARD (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 228TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7226
Mailing Address - Country:US
Mailing Address - Phone:425-868-1112
Mailing Address - Fax:
Practice Address - Street 1:526 228TH AVE NE
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7226
Practice Address - Country:US
Practice Address - Phone:425-868-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00013807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist