Provider Demographics
NPI:1295786432
Name:GIBSON PHARMACY, LLC
Entity type:Organization
Organization Name:GIBSON PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
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:903-675-7069
Mailing Address - Street 1:600 S PALESTINE ST
Mailing Address - Street 2:SUITE 100
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:903-677-9459
Practice Address - Street 1:600 S PALESTINE ST
Practice Address - Street 2:SUITE 100
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:903-677-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX025233336L0003X, 332B00000X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142443Medicaid
TX142443Medicaid