Healthcare Provider Details

I. General information

NPI: 1114026895
Provider Name (Legal Business Name): GIBSON DRUG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N. MAIN ST.
WAKEENEY KS
67672
US

IV. Provider business mailing address

125 N. MAIN ST.
WAKEENEY KS
67672
US

V. Phone/Fax

Practice location:
  • Phone: 785-743-5753
  • Fax:
Mailing address:
  • Phone: 785-743-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number10830153
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. BERNITA AUGUSTINE
Title or Position: PRESIDENT
Credential:
Phone: 785-743-5753