Individual
JUSTIN WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1650 W MALONEY AVE, GALLUP, NM 87301-3305
(505) 722-3823
Mailing address
1650 W MALONEY AVE, GALLUP, NM 87301-3305
(505) 722-3823
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
13889
NV
183500000X
Pharmacist
18855
IA
183500000X
Pharmacist
Primary
RP00007923
NM
Other
Enumeration date
07/16/2014
Last updated
07/16/2014
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