Provider Demographics
NPI:1184313355
Name:FOREVER YOUNG PHARMACY
Entity type:Organization
Organization Name:FOREVER YOUNG PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FREDERICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:714-757-7584
Mailing Address - Street 1:6351 CORTE DEL ABETO STE 111
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1429
Mailing Address - Country:US
Mailing Address - Phone:714-757-7584
Mailing Address - Fax:
Practice Address - Street 1:6351 CORTE DEL ABETO STE 111
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1429
Practice Address - Country:US
Practice Address - Phone:714-757-7584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy