Provider Demographics
NPI:1447713185
Name:WAGNER, JORDAN JAY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:JAY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50595-3066
Mailing Address - Country:US
Mailing Address - Phone:515-290-0745
Mailing Address - Fax:
Practice Address - Street 1:2350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WEBSTER CITY
Practice Address - State:IA
Practice Address - Zip Code:50595-6600
Practice Address - Country:US
Practice Address - Phone:515-832-7745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist