Provider Demographics
NPI:1891338463
Name:WAGNER, NORA (PHARMD)
Entity type:Individual
Prefix:
First Name:NORA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10634 SAND MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-5068
Mailing Address - Country:US
Mailing Address - Phone:913-523-3844
Mailing Address - Fax:
Practice Address - Street 1:1750 W UINTAH ST STE A
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-2972
Practice Address - Country:US
Practice Address - Phone:719-636-5043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA808613336C0003X
CO246773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy