Provider Demographics
NPI:1952034514
Name:GIPSON, JOHN (VA60681359)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GIPSON
Suffix:
Gender:M
Credentials:VA60681359
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:909 YELM AVE E
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9425
Mailing Address - Country:US
Mailing Address - Phone:360-458-9011
Mailing Address - Fax:360-458-9110
Practice Address - Street 1:909 YELM AVE E
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9425
Practice Address - Country:US
Practice Address - Phone:360-458-9011
Practice Address - Fax:360-458-9110
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60681359183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician