=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821160615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIBSON FAMILY PHARMACY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 W 21ST ST
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-762-4579
-----------------------------------------------------
Fax | 575-762-9612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 W 21ST ST
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-762-4579
-----------------------------------------------------
Fax | 575-762-9612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHARMACIST
-----------------------------------------------------
Name | JIM HERMAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 575-762-4579
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PH1134
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------