Provider Demographics
NPI:1104093046
Name:YOUNGBERG, RICHARD ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:YOUNGBERG
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:PO BOX 840688
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0688
Mailing Address - Country:US
Mailing Address - Phone:800-225-5967
Mailing Address - Fax:909-799-4364
Practice Address - Street 1:800 BIERMANN CT
Practice Address - Street 2:SUITE B
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2151
Practice Address - Country:US
Practice Address - Phone:800-225-5967
Practice Address - Fax:909-799-4364
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist