Healthcare Provider Details

I. General information

NPI: 1114915584
Provider Name (Legal Business Name): GIBSON'S DISCOUNT DRUGS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S MAIN ST
RED BUD IL
62278-1316
US

IV. Provider business mailing address

1506 S MAIN ST
RED BUD IL
62278-1316
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-6231
  • Fax: 618-282-4090
Mailing address:
  • Phone: 618-282-6231
  • Fax: 618-282-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054007133
License Number StateIL

VIII. Authorized Official

Name: STEVEN GIBSON
Title or Position: OWNER/PIC
Credential: RPH
Phone: 618-318-5340