Provider Demographics
NPI:1780971226
Name:YOUNG, JIM E (RPH)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:E
Last Name:YOUNG
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 1:4501 OLD FREEZE OUT RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9578
Mailing Address - Country:US
Mailing Address - Phone:208-365-4926
Mailing Address - Fax:
Practice Address - Street 1:640 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9461
Practice Address - Country:US
Practice Address - Phone:208-365-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist