Provider Demographics
NPI:1902080286
Name:WAGNER, JEANNINE OBRIEN (RPH)
Entity Type:Individual
Prefix:MS
First Name:JEANNINE
Middle Name:OBRIEN
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 1:1050 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2908
Mailing Address - Country:US
Mailing Address - Phone:585-216-3001
Mailing Address - Fax:585-216-3001
Practice Address - Street 1:1050 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2908
Practice Address - Country:US
Practice Address - Phone:585-216-3001
Practice Address - Fax:585-216-3001
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-22
Last Update Date:2007-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039056-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist