Healthcare Provider Details

I. General information

NPI: 1972815975
Provider Name (Legal Business Name): LEVON GIBSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W AMES CT SUITE 200
PLAINVIEW NY
11803-2304
US

IV. Provider business mailing address

2300 PEACHFORD RD STE 1408
DUNWOODY GA
30338-5846
US

V. Phone/Fax

Practice location:
  • Phone: 516-938-8080
  • Fax:
Mailing address:
  • Phone: 404-431-3871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number054170
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier054170
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerPHARMACIST LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: