Provider Demographics
NPI:1275125874
Name:YOUNG, KIM DEANNA (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DEANNA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12781 JESSIE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-1683
Mailing Address - Country:US
Mailing Address - Phone:951-318-0374
Mailing Address - Fax:
Practice Address - Street 1:1010 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1806
Practice Address - Country:US
Practice Address - Phone:909-954-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10974183500000X
CA46564183500000X
CO12469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist