Provider Demographics
NPI:1639241144
Name:GIBSONBURG PHARMACY INC
Entity Type:Organization
Organization Name:GIBSONBURG PHARMACY INC
Other - Org Name:PILLS N PACKAGES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-637-7441
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:ELMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43416-0011
Mailing Address - Country:US
Mailing Address - Phone:419-862-2982
Mailing Address - Fax:
Practice Address - Street 1:350 RICE ST
Practice Address - Street 2:
Practice Address - City:ELMORE
Practice Address - State:OH
Practice Address - Zip Code:43416
Practice Address - Country:US
Practice Address - Phone:419-862-2982
Practice Address - Fax:419-862-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OH0204556503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0618559Medicaid
2076680OtherPK
2076680OtherPK