Active NPI
Jason Waggoner, RPH
- Pharmacist
- Mattoon, IL
National Provider Identifier
1033713524
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 051-289951
- Practice address
- 1316 Charleston Ave
Mattoon, IL 61938-4016 - Phone
- (217) 258-2920
- NPI assigned
- Nov 24, 2020
- Last updated
- Nov 24, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 051-289951 | IL | Primary |
Addresses
Primary practice location
1316 Charleston Ave
Mattoon, IL 61938-4016
Mailing address
1316 Charleston Ave
Mattoon, IL 61938-4016
Phone (217) 258-2920
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 051-289951 | IL | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Highland Park CVS LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1606176000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1606176000000",
"number": "1033713524",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1316 CHARLESTON AVE",
"city": "MATTOON",
"state": "IL",
"postal_code": "619384016",
"telephone_number": "217-258-2920"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1316 CHARLESTON AVE",
"city": "MATTOON",
"state": "IL",
"postal_code": "619384016",
"telephone_number": "217-258-2920"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGGONER",
"first_name": "JASON",
"credential": "RPH",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-11-24",
"last_updated": "2020-11-24",
"certification_date": "2020-11-24",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "IL",
"license": "051-289951",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mattoon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.