Healthcare Provider Details

I. General information

NPI: 1457845596
Provider Name (Legal Business Name): GIBE GENETI GELAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E MCCOY LN UNIT 9B
SANTA MARIA CA
93455-1387
US

IV. Provider business mailing address

310 E MCCOY LN UNIT 9B
SANTA MARIA CA
93455-1387
US

V. Phone/Fax

Practice location:
  • Phone: 808-854-6422
  • Fax:
Mailing address:
  • Phone: 808-854-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number78302
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: