Provider Demographics
NPI:1386861425
Name:GIBSON, REGETTA ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:REGETTA
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BRYANT VIA
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2316
Mailing Address - Country:US
Mailing Address - Phone:405-273-9102
Mailing Address - Fax:405-275-5111
Practice Address - Street 1:1102 W MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1743
Practice Address - Country:US
Practice Address - Phone:405-878-5660
Practice Address - Fax:405-878-3497
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist