Provider Demographics
NPI:1770331837
Name:GIBSON, LONDON
Entity type:Individual
Prefix:
First Name:LONDON
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 1:69 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801
Mailing Address - Country:US
Mailing Address - Phone:304-436-3380
Mailing Address - Fax:
Practice Address - Street 1:69 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2440
Practice Address - Country:US
Practice Address - Phone:304-436-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist