Provider Demographics
NPI:1053479758
Name:GIBSON MCWHIRT CORP
Entity Type:Organization
Organization Name:GIBSON MCWHIRT CORP
Other - Org Name:PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNORP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:660-826-2431
Mailing Address - Street 1:700 S LIMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-3900
Mailing Address - Country:US
Mailing Address - Phone:660-826-2431
Mailing Address - Fax:660-826-2713
Practice Address - Street 1:700 S LIMIT AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-3900
Practice Address - Country:US
Practice Address - Phone:660-826-2431
Practice Address - Fax:660-826-2713
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON MCWHIRT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO028824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600203400Medicaid
MO0798120001Medicare NSC