Provider Demographics
NPI:1659473429
Name:GIBBS, BRADLEY E (RPH)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:E
Last Name:GIBBS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 CLEAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7780
Mailing Address - Country:US
Mailing Address - Phone:505-907-2924
Mailing Address - Fax:
Practice Address - Street 1:1771 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4757
Practice Address - Country:US
Practice Address - Phone:386-767-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3954183500000X
FLPS56034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist