Provider Demographics
NPI:1730519232
Name:YOUNG, MODANIET (PHARM D)
Entity type:Individual
Prefix:
First Name:MODANIET
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12815 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3116
Mailing Address - Country:US
Mailing Address - Phone:951-601-6044
Mailing Address - Fax:951-601-6058
Practice Address - Street 1:12815 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3116
Practice Address - Country:US
Practice Address - Phone:951-601-6044
Practice Address - Fax:951-601-6058
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist