Provider Demographics
NPI:1871934299
Name:YOUNGBLOOD, ADAM LEO KEITH (PHARMD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:LEO KEITH
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 FETHERSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1619
Mailing Address - Country:US
Mailing Address - Phone:978-761-5442
Mailing Address - Fax:
Practice Address - Street 1:3800 SE 22ND AVE
Practice Address - Street 2:MAIL STOP: 04002/31D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2918
Practice Address - Country:US
Practice Address - Phone:503-797-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-14
Last Update Date:2013-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist