Provider Demographics
NPI:1457518896
Name:WAGNER, HEIDI MARIA (RPH)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIA
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 1:9163 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8392
Mailing Address - Country:US
Mailing Address - Phone:810-658-0828
Mailing Address - Fax:
Practice Address - Street 1:2333 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1147
Practice Address - Country:US
Practice Address - Phone:810-744-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020286171835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist