Provider Demographics
NPI:1619566783
Name:GIBBONS, GREGORY N (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:N
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1189
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948
Mailing Address - Country:US
Mailing Address - Phone:809-865-2722
Mailing Address - Fax:509-865-2329
Practice Address - Street 1:117 SO. TOPPENISH AVE.
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948
Practice Address - Country:US
Practice Address - Phone:509-865-2722
Practice Address - Fax:509-865-2329
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00011366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty