Provider Demographics
NPI:1538430186
Name:YOUNGBLOOD, WILLARD OLIVER (RPH)
Entity type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:OLIVER
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 7TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265
Mailing Address - Country:US
Mailing Address - Phone:256-782-9873
Mailing Address - Fax:
Practice Address - Street 1:800 NOBLE ST
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-5626
Practice Address - Country:US
Practice Address - Phone:256-236-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7940OtherPHARMACIST LICENSE