Healthcare Provider Details

I. General information

NPI: 1821442856
Provider Name (Legal Business Name): GIBSON PHARMACY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E WINCHESTER ST
MURRAY UT
84107-7305
US

IV. Provider business mailing address

240 E WINCHESTER ST
MURRAY UT
84107-7305
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-5526
  • Fax: 801-262-0125
Mailing address:
  • Phone: 801-262-5526
  • Fax: 801-262-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9754571-1703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier2160207
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: BYRON ROBINSON
Title or Position: OWNER/MANAGER
Credential:
Phone: 801-262-5526