Provider Demographics
NPI:1497197602
Name:GIBBS, SUSAN DIANE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DIANE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 INLET LOOP
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-4446
Mailing Address - Country:US
Mailing Address - Phone:408-623-1116
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:119
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-756-8037
Practice Address - Fax:541-756-7503
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist