Provider Demographics
NPI:1184225799
Name:YOUNG, JOBY LEE
Entity Type:Individual
Prefix:
First Name:JOBY
Middle Name:LEE
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 1:3301 SW 104TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7043
Mailing Address - Country:US
Mailing Address - Phone:405-300-6572
Mailing Address - Fax:405-300-6582
Practice Address - Street 1:3301 SW 104TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7043
Practice Address - Country:US
Practice Address - Phone:405-300-6572
Practice Address - Fax:405-300-6582
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist