Healthcare Provider Details

I. General information

NPI: 1184313355
Provider Name (Legal Business Name): FOREVER YOUNG PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6351 CORTE DEL ABETO STE 111
CARLSBAD CA
92011-1429
US

IV. Provider business mailing address

6351 CORTE DEL ABETO STE 111
CARLSBAD CA
92011-1429
US

V. Phone/Fax

Practice location:
  • Phone: 714-757-7584
  • Fax:
Mailing address:
  • Phone: 714-757-7584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. DANE DAVID FREDERICKSEN
Title or Position: OWNER
Credential: PHARM. D.
Phone: 714-757-7584