Provider Demographics
NPI:1629626775
Name:GIBILANTE, MICHAEL I
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GIBILANTE
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 2ND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3833
Mailing Address - Country:US
Mailing Address - Phone:215-355-2004
Mailing Address - Fax:
Practice Address - Street 1:209 2ND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3833
Practice Address - Country:US
Practice Address - Phone:215-355-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045781L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist