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General NPI Number Information
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NPI Number | 1386062529
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Entity Type | Individual
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Provider Name | ROGER GIBSON
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Gender | Male
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Dates
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Enumeration Date | 04/04/2014
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Last Update Date | 04/04/2014
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Provider Practice Location Address
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Address Line | 1676 WESTPARK DR
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City | BOWLING GREEN
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State | KY
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Zip | 42104
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Country | US
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Telephone | 888-555-1212
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Fax |
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Provider Business Mailing Address
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Address Line | 140 TRIPLE CROWN CT
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City | BOWLING GREEN
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State | KY
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Zip | 42104-8567
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 12015
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 012567
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License Number State | KY
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