Provider Demographics
NPI:1477570166
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:GIBSON FAMILY PHARMACY, A MEMBER OF THE MEDICINE SHOPPE FAMILY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-784-4251
Mailing Address - Street 1:1120 N. MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-784-8545
Mailing Address - Fax:217-784-8039
Practice Address - Street 1:104 N. SANGAMON AVE
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1343
Practice Address - Country:US
Practice Address - Phone:217-784-8545
Practice Address - Fax:217-784-8039
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540152273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1422853OtherNCPDP #
IL550868762001Medicaid
IL550868762001Medicaid
IL5246440001Medicare NSC