Provider Demographics
NPI:1992114177
Name:WAGGONER, CHRISTY (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:
Last Name:WAGGONER
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 1:5108 CLEVELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-8002
Mailing Address - Country:US
Mailing Address - Phone:208-455-0800
Mailing Address - Fax:208-455-3539
Practice Address - Street 1:1775 E IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914
Practice Address - Country:US
Practice Address - Phone:541-889-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012207183500000X, 1835P0018X
IDP5368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist