Provider Demographics
NPI:1477824761
Name:YOUNG, ERIC (PHARMD, PHC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHARMD, PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-216-0332
Mailing Address - Fax:505-982-0279
Practice Address - Street 1:649 HARKLE RD STE E
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4765
Practice Address - Country:US
Practice Address - Phone:505-955-9454
Practice Address - Fax:505-216-9067
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007744183500000X
NMCP000002841835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51108861Medicaid