Basic Information
| Provider Information | |||||||||
| NPI: | 1417584640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D, MBA, RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 SUNNYDALE LN SE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559043922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054641634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1798 OLD STAGE RD | ||||||||
| Address2: | |||||||||
| City: | DECORAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 521017497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633828456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 23241 | IA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.