Provider Demographics
NPI:1407974884
Name:YOUNGBLOOD, WILTON EARL (RPH)
Entity Type:Individual
Prefix:
First Name:WILTON
Middle Name:EARL
Last Name:YOUNGBLOOD
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 1:4515 ROBIN LANE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707
Mailing Address - Country:US
Mailing Address - Phone:432-367-3407
Mailing Address - Fax:432-366-0336
Practice Address - Street 1:1107 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762
Practice Address - Country:US
Practice Address - Phone:432-367-3407
Practice Address - Fax:432-366-0336
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist