Healthcare Provider Details

I. General information

NPI: 1912500596
Provider Name (Legal Business Name): ANITA GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NEWSOME DR STE A
MARKED TREE AR
72365-2018
US

IV. Provider business mailing address

203 NEWSOME DR STE A
MARKED TREE AR
72365-2018
US

V. Phone/Fax

Practice location:
  • Phone: 870-358-2135
  • Fax: 870-358-4055
Mailing address:
  • Phone: 870-358-2135
  • Fax: 870-358-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD07935
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: