Provider Demographics
NPI:1679131759
Name:WAGNER, SHELBY (PHARMD)
Entity type:Individual
Prefix:
First Name:SHELBY
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 1:2701 S MINNESOTA AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4746
Mailing Address - Country:US
Mailing Address - Phone:605-367-2000
Mailing Address - Fax:
Practice Address - Street 1:1507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1017
Practice Address - Country:US
Practice Address - Phone:605-292-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist