Provider Demographics
NPI:1720093370
Name:GIBBONS PHARMACIES LLC
Entity Type:Organization
Organization Name:GIBBONS PHARMACIES LLC
Other - Org Name:ELFERS LYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-865-2722
Mailing Address - Street 1:820 MEMORIAL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-2504
Mailing Address - Country:US
Mailing Address - Phone:509-786-3200
Mailing Address - Fax:509-786-7074
Practice Address - Street 1:820 MEMORIAL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-2504
Practice Address - Country:US
Practice Address - Phone:509-786-3200
Practice Address - Fax:509-786-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000559193336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106990OtherPK
WA6021679Medicaid
2106990OtherPK