Provider Demographics
NPI:1982977674
Name:YOUNGBLOOD, DAVID QUINN
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:QUINN
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1495
Mailing Address - Country:US
Mailing Address - Phone:208-549-8777
Mailing Address - Fax:208-549-8780
Practice Address - Street 1:1545 E 6TH ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1495
Practice Address - Country:US
Practice Address - Phone:208-549-8777
Practice Address - Fax:208-549-8780
Is Sole Proprietor?:No
Enumeration Date:2012-02-11
Last Update Date:2012-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP6013OtherSTATE PHARMACIST LICENSE