Provider Demographics
NPI:1083911739
Name:GIBBONS, MILLER WALTON JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:MILLER
Middle Name:WALTON
Last Name:GIBBONS
Suffix:JR
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 1:718 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-2738
Mailing Address - Country:US
Mailing Address - Phone:252-792-2269
Mailing Address - Fax:252-792-7837
Practice Address - Street 1:718 EAST BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2738
Practice Address - Country:US
Practice Address - Phone:252-792-2269
Practice Address - Fax:252-792-7837
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist