Provider Demographics
NPI:1528183902
Name:JAMES L. YOUNGBLOOD BELTLINE FAMILY PHARMACY
Entity Type:Organization
Organization Name:JAMES L. YOUNGBLOOD BELTLINE FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-0052
Mailing Address - Street 1:2711 CORNER CT
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5328
Mailing Address - Country:US
Mailing Address - Phone:618-462-0052
Mailing Address - Fax:618-462-8114
Practice Address - Street 1:2711 CORNER CT
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5328
Practice Address - Country:US
Practice Address - Phone:618-462-0052
Practice Address - Fax:618-462-8114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54-5740333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL1290520001Medicare ID - Type Unspecified