Provider Demographics
NPI:1346523024
Name:GIBSON, MELISSA TAYLOR (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:TAYLOR
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 RED LEAF CT
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-8028
Mailing Address - Country:US
Mailing Address - Phone:770-483-0520
Mailing Address - Fax:
Practice Address - Street 1:1783 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1295
Practice Address - Country:US
Practice Address - Phone:770-483-5644
Practice Address - Fax:770-483-3880
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020110183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist