Provider Demographics
NPI:1164844601
Name:YOUNG, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 N 79TH AVE APT 2066
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8351
Mailing Address - Country:US
Mailing Address - Phone:630-205-4840
Mailing Address - Fax:
Practice Address - Street 1:6145 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1940
Practice Address - Country:US
Practice Address - Phone:602-973-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist