Provider Demographics
NPI:1588941462
Name:WAGNER, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5645
Mailing Address - Country:US
Mailing Address - Phone:207-784-3294
Mailing Address - Fax:
Practice Address - Street 1:27 EAST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6645
Practice Address - Country:US
Practice Address - Phone:207-784-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR31101835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist