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General NPI Number Information
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NPI Number | 1659473429
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Entity Type | Individual
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Provider Name | BRADLEY E GIBBS RPH
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Gender | Male
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Dates
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Enumeration Date | 09/02/2006
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Last Update Date | 12/01/2020
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Provider Practice Location Address
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Address Line | 1771 DUNLAWTON AVE
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City | PORT ORANGE
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State | FL
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Zip | 32127-4757
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Country | US
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Telephone | 386-767-6082
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Fax |
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Provider Business Mailing Address
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Address Line | 841 CLEAR LAKE DR
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City | PORT ORANGE
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State | FL
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Zip | 32127-7780
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Country | US
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Telephone | 505-907-2924
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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 | 3954
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License Number State | NM
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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 | PS56034
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License Number State | FL
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