Provider Demographics
NPI:1922537000
Name:YOUNG LIFE ENTERPRISE LLC
Entity Type:Organization
Organization Name:YOUNG LIFE ENTERPRISE LLC
Other - Org Name:YOUNG LIFE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-549-9671
Mailing Address - Street 1:PO BOX 371106
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-1106
Mailing Address - Country:US
Mailing Address - Phone:678-772-8623
Mailing Address - Fax:
Practice Address - Street 1:1769 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3276
Practice Address - Country:US
Practice Address - Phone:678-772-8623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy