Provider Demographics
NPI:1316220650
Name:GIBSON, KEITH EDWARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:GIBSON
Suffix:
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 1:1650 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3931
Mailing Address - Country:US
Mailing Address - Phone:618-462-5386
Mailing Address - Fax:
Practice Address - Street 1:1650 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3931
Practice Address - Country:US
Practice Address - Phone:618-462-5386
Practice Address - Fax:618-462-5852
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-293654183500000X
MO2010028189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist