Provider Demographics
NPI:1639765779
Name:GIBBS, CHARLES S
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:GIBBS
Suffix:
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 1:141 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-1359
Mailing Address - Country:US
Mailing Address - Phone:508-543-6174
Mailing Address - Fax:508-543-5956
Practice Address - Street 1:141 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-1359
Practice Address - Country:US
Practice Address - Phone:508-543-6174
Practice Address - Fax:508-543-5956
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH22789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist