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General NPI Number Information
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NPI Number | 1871620211
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Entity Type | Organization
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Legal Business Name | HENRY W YOUNGBLOOD
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 10/14/2014
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Provider Practice Location Address
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Address Line | 402 ALABAMA ST N
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City | BROXTON
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State | GA
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Zip | 31519-6001
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Country | US
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Telephone | 912-359-2362
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Fax | 912-359-3607
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Provider Business Mailing Address
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Address Line | PO BOX 758
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City | BROXTON
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State | GA
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Zip | 31519-0758
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Country | US
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Telephone | 912-359-2362
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Fax | 912-359-3607
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Authorized Official
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Title or Position | OWNER
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Name | HENRY YOUNGBLOOD
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Credential |
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Telephone | 912-359-2362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE010064
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License Number State | GA
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