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General NPI Number Information
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NPI Number | 1629355409
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Entity Type | Individual
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Provider Name | CHESTEVIA GIBSON PHARMD
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Gender | Female
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Dates
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Enumeration Date | 11/08/2011
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Last Update Date | 11/08/2011
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Provider Practice Location Address
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Address Line | 1207 W BROADWAY AVE
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City | FOREST LAKE
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State | MN
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Zip | 55025-1418
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Country | US
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Telephone | 651-255-1887
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Fax |
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Provider Business Mailing Address
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Address Line | 10895 BIRCH LN
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City | WOODBURY
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State | MN
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Zip | 55129-6243
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Country | US
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Telephone | 651-470-0457
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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 | 120304
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License Number State | MN
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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 | PS37448
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License Number State | FL
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