Provider Demographics
NPI:1538231907
Name:DENNIS WAGNER
Entity type:Organization
Organization Name:DENNIS WAGNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-789-6881
Mailing Address - Street 1:2703 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5246
Mailing Address - Country:US
Mailing Address - Phone:405-789-6881
Mailing Address - Fax:405-787-9793
Practice Address - Street 1:2703 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5246
Practice Address - Country:US
Practice Address - Phone:405-789-6881
Practice Address - Fax:405-787-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-41683336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236840AMedicaid
2072645OtherPK
OK100805600BMedicaid
0730450001Medicare NSC