Provider Demographics
NPI:1821160615
Name:GIBSON FAMILY PHARMACY PC
Entity Type:Organization
Organization Name:GIBSON FAMILY PHARMACY PC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-762-4579
Mailing Address - Street 1:1801 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4023
Mailing Address - Country:US
Mailing Address - Phone:575-762-4579
Mailing Address - Fax:575-762-9612
Practice Address - Street 1:1801 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4023
Practice Address - Country:US
Practice Address - Phone:575-762-4579
Practice Address - Fax:575-762-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH1134333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3200362OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NM67454Medicaid
NM67454Medicaid