Provider Demographics
NPI:1740865260
Name:GIBSON, MELLODIEMOLLY
Entity type:Individual
Prefix:
First Name:MELLODIEMOLLY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 CRESTBROOK BEND LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-4688
Mailing Address - Country:US
Mailing Address - Phone:832-657-9862
Mailing Address - Fax:
Practice Address - Street 1:1521 INTERSTATE 35 N
Practice Address - Street 2:
Practice Address - City:BELLMEAD
Practice Address - State:TX
Practice Address - Zip Code:76705-2466
Practice Address - Country:US
Practice Address - Phone:254-867-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist