Provider Demographics
NPI:1255659314
Name:HARRIS, MIRIAM GIBSON
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:GIBSON
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MIRIAM
Other - Middle Name:DENISE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:11415 SAINT IVES CT
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-8492
Mailing Address - Country:US
Mailing Address - Phone:251-626-9274
Mailing Address - Fax:
Practice Address - Street 1:6000 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-0001
Practice Address - Country:US
Practice Address - Phone:850-505-6934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist