Basic Information
| Provider Information | |||||||||
| NPI: | 1477824761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD, PHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6880 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875026880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052160332 | ||||||||
| FaxNumber: | 5059820279 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 HARKLE RD STE E | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059898200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2012 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP00007744 | NM | N | Pharmacy Service Providers | Pharmacist | 1835P0018X | CP00000284 | NM | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | 51108861 | 05 | NM | MEDICAID |