Provider Demographics
NPI:1558502823
Name:SIDBURY, GISELE MASON (PHARMD)
Entity Type:Individual
Prefix:
First Name:GISELE
Middle Name:MASON
Last Name:SIDBURY
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 1:10503 FURLING CT
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20623-1331
Mailing Address - Country:US
Mailing Address - Phone:240-681-3538
Mailing Address - Fax:
Practice Address - Street 1:316 TALBOTT AVE STE A
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4334
Practice Address - Country:US
Practice Address - Phone:301-617-0555
Practice Address - Fax:301-617-9882
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPHA24555183500000X
MD09485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist