Provider Demographics
NPI:1780775502
Name:GIBSON, TONI KAY (DPH)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:KAY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1173
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74602-1173
Mailing Address - Country:US
Mailing Address - Phone:580-765-4780
Mailing Address - Fax:580-765-0668
Practice Address - Street 1:301 WEST GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5118
Practice Address - Country:US
Practice Address - Phone:580-765-4456
Practice Address - Fax:580-765-0668
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0237820001Medicare ID - Type Unspecified