Provider Demographics
NPI:1629355409
Name:GIBSON, CHESTEVIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHESTEVIA
Middle Name:
Last Name:GIBSON
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 1:10895 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6243
Mailing Address - Country:US
Mailing Address - Phone:651-470-0457
Mailing Address - Fax:
Practice Address - Street 1:1207 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1418
Practice Address - Country:US
Practice Address - Phone:651-255-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120304183500000X
FLPS37448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist