Healthcare Provider Details

I. General information

NPI: 1194353805
Provider Name (Legal Business Name): MR. RYAN WESLEY GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 E MULLAN AVE
POST FALLS ID
83854-8939
US

IV. Provider business mailing address

2600 E SELTICE WAY STE A-127
POST FALLS ID
83854-7991
US

V. Phone/Fax

Practice location:
  • Phone: 208-777-4502
  • Fax:
Mailing address:
  • Phone: 208-691-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP11012
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: