Provider Demographics
NPI:1043341951
Name:GIBSON FAMILY PHARMACY PC
Entity Type:Organization
Organization Name:GIBSON FAMILY PHARMACY PC
Other - Org Name:FAMILY INSTITUTIONAL PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-762-9621
Mailing Address - Street 1:1801 W 21ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 W 21ST ST STE B
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4023
Practice Address - Country:US
Practice Address - Phone:505-762-9621
Practice Address - Fax:505-762-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336I0012X
NMPH0018183336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3209346OtherOTHER ID NUMBER
3209346OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NM661617Medicaid