Provider Demographics
NPI:1194447052
Name:YOUNG, BLAIRE
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
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 2497
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-7397
Mailing Address - Country:US
Mailing Address - Phone:936-465-0172
Mailing Address - Fax:
Practice Address - Street 1:65 AUGUSTA DRIVE
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676
Practice Address - Country:US
Practice Address - Phone:936-465-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist