Simon B Van Wagenen, RPH

Primary specialty

PharmacistTaxonomy code 183500000X

License

PS16532 Issued in FL

Practice address

470 W Madison St
Starke, FL 32091-3926

Phone

(904) 964-6759

Fax

(904) 964-5315

NPI assigned

Mar 8, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Registered Pharmacist

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173312000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1790816072",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15604 SW 161ST ST",
            "city": "BROOKER",
            "state": "FL",
            "postal_code": "326222540",
            "telephone_number": "904-449-3937",
            "fax_number": "904-964-5315"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "470 W MADISON ST",
            "city": "STARKE",
            "state": "FL",
            "postal_code": "320913926",
            "telephone_number": "904-964-6759",
            "fax_number": "904-964-5315"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VAN WAGENEN",
        "first_name": "SIMON",
        "middle_name": "B",
        "name_prefix": "Mr.",
        "credential": "RPH",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-03-08",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "FL",
            "license": "PS16532",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Upperline Healthcare, PC
• Linda A. Vanwulfen, MA, MSW
• Kimberly Lynn Wainwright, PTA
• Rylee Wainwright, PA-C
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP

• Pharmacist in Starke, FL
• Providers in Starke, FL by specialty
• Pharmacist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.