Provider Demographics
NPI:1629345533
Name:GIBSON, TEIRA LYNN
Entity Type:Individual
Prefix:
First Name:TEIRA
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 FLOYD RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1608
Mailing Address - Country:US
Mailing Address - Phone:770-819-9420
Mailing Address - Fax:
Practice Address - Street 1:5000 FLOYD RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1608
Practice Address - Country:US
Practice Address - Phone:770-819-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-20
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist