Provider Demographics
NPI:1265867360
Name:YOUNG, FRED L (RPH)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 DREAMWOLD WAY
Mailing Address - Street 2:
Mailing Address - City:MICHIANA SHORES
Mailing Address - State:IN
Mailing Address - Zip Code:46360-1211
Mailing Address - Country:US
Mailing Address - Phone:708-691-1145
Mailing Address - Fax:219-972-0364
Practice Address - Street 1:430 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1018
Practice Address - Country:US
Practice Address - Phone:219-972-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-08
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2601888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMedicare UPIN