Provider Demographics
NPI:1821578865
Name:GIBSON PHARMACY, LLC
Entity Type:Organization
Organization Name:GIBSON PHARMACY, LLC
Other - Org Name:GIBSON PRESCRIPTION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON KOCIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:903-675-7062
Mailing Address - Street 1:600 S PALESTINE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3310
Mailing Address - Country:US
Mailing Address - Phone:903-675-7069
Mailing Address - Fax:903-677-5454
Practice Address - Street 1:600 S PALESTINE ST STE 100
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3310
Practice Address - Country:US
Practice Address - Phone:903-675-7069
Practice Address - Fax:903-677-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX025233336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy