Provider Demographics
NPI:1356637847
Name:YOUNG, CHARLES WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WAYNE
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 1:14546 DELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-9744
Mailing Address - Country:US
Mailing Address - Phone:218-828-9219
Mailing Address - Fax:218-828-9219
Practice Address - Street 1:14546 DELLWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-9744
Practice Address - Country:US
Practice Address - Phone:218-828-9219
Practice Address - Fax:218-828-9219
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist