Healthcare Provider Details

I. General information

NPI: 1457337339
Provider Name (Legal Business Name): SHELBY GLEN YOUNG R. PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 W MAIN ST
NEW LEBANON OH
45345-9173
US

IV. Provider business mailing address

1391 HICKORYVIEW CT
CENTERVILLE OH
45458-9681
US

V. Phone/Fax

Practice location:
  • Phone: 937-687-9711
  • Fax: 937-687-7052
Mailing address:
  • Phone: 937-885-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-2-12661
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: