Provider Demographics
NPI:1417250101
Name:GIBB, BRYAN JORDON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JORDON
Last Name:GIBB
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 1:514 N RIPPLEROCK PL
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5127
Mailing Address - Country:US
Mailing Address - Phone:801-540-9496
Mailing Address - Fax:
Practice Address - Street 1:65 SE GOODFELLOW ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3016
Practice Address - Country:US
Practice Address - Phone:541-889-6288
Practice Address - Fax:541-889-5675
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012482183500000X
IDP6436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist