Provider Demographics
NPI:1992879092
Name:WAGNER, KRISTIN JO
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JO
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35925 N PIKE RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-9147
Mailing Address - Country:US
Mailing Address - Phone:509-292-8398
Mailing Address - Fax:
Practice Address - Street 1:3919 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1349
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:509-444-7810
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00020076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist