Basic Information
| Provider Information | |||||||||
| NPI: | 1962491399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGERS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 MALLARD DR | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407419748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068773190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 LEGACY DR | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404039594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599862323 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 012026 | KY | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 012026 | 01 | KY | STATE LICENSE | OTHER |