Provider Demographics
NPI:1114915584
Name:GIBSON'S DISCOUNT DRUGS, INC
Entity Type:Organization
Organization Name:GIBSON'S DISCOUNT DRUGS, INC
Other - Org Name:GIBSON'S DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-318-5340
Mailing Address - Street 1:1506 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1316
Mailing Address - Country:US
Mailing Address - Phone:618-282-6231
Mailing Address - Fax:618-282-4090
Practice Address - Street 1:1506 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1316
Practice Address - Country:US
Practice Address - Phone:618-282-6231
Practice Address - Fax:618-282-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540071333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017692OtherPK
IL371087234Medicaid
IL=========001Medicaid