MEDICARE: MRS. TAMMY CHARLYN GIBSON RPH DPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	9030	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P009030	OTHER	KY	PHARMACIST

General Provider Information

NPI Number	:	1053025494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAMMY CHARLYN GIBSON RPH DPH

Provider Business Mailing Address
First Line	:	9344 CROSS MEADOWS CIR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-5618
Country	:	US
Telephone Number	:	502-797-0156
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N HURSTBOURNE PKWY STE 174
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-5138
Country	:	US
Telephone Number	:	502-690-4462
Fax Number	:	502-690-4466

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2023
Last Update Date	:	01/10/2023

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