Provider Demographics
NPI:1134231616
Name:GRAHAM GIBSON'T PHY., INC.
Entity type:Organization
Organization Name:GRAHAM GIBSON'T PHY., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LOWRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:940-549-4600
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-1140
Mailing Address - Country:US
Mailing Address - Phone:940-549-4600
Mailing Address - Fax:940-549-4666
Practice Address - Street 1:1005 HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-3835
Practice Address - Country:US
Practice Address - Phone:940-549-4600
Practice Address - Fax:940-549-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX037973336C0003X
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4521224OtherNCPDP (NABP) NUMBER
TX4521224Medicaid
TX0810580001Medicare NSC