Provider Demographics
NPI:1659489144
Name:GIBSON, GARY G (PD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:G
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 RANCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08078183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist