Healthcare Provider Details

I. General information

NPI: 1548038334
Provider Name (Legal Business Name): ILENE YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILENE CAMERON

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

310 E MCCOY LN UNIT 9I
SANTA MARIA CA
93455-1361
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-2778
  • Fax:
Mailing address:
  • Phone: 330-904-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number87887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03442141
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: