Provider Demographics
NPI:1053429415
Name:WAGNER, HEATHER (RPH)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:2002 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2167
Mailing Address - Country:US
Mailing Address - Phone:317-839-6561
Mailing Address - Fax:317-839-6781
Practice Address - Street 1:2002 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2167
Practice Address - Country:US
Practice Address - Phone:317-839-6561
Practice Address - Fax:317-839-6781
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017900A183500000X, 183500000X
FLPS39176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist