Provider Demographics
NPI:1386236222
Name:WAGNER, LAWRENCE A (RPH)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
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 1:4320 WORNALL RD STE 128
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5949
Mailing Address - Country:US
Mailing Address - Phone:816-932-2688
Mailing Address - Fax:816-932-8126
Practice Address - Street 1:4320 WORNALL RD STE 128
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5949
Practice Address - Country:US
Practice Address - Phone:816-932-2688
Practice Address - Fax:816-932-8126
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10995183500000X
MO2013005453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist