Provider Demographics
NPI:1538439666
Name:GIBSON, SUE LEEUWENBURG (RPH)
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:LEEUWENBURG
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 LEESBURG DR
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9386
Mailing Address - Country:US
Mailing Address - Phone:910-547-9451
Mailing Address - Fax:
Practice Address - Street 1:1531 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-2608
Practice Address - Country:US
Practice Address - Phone:910-457-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0105296Medicaid
NC3434139OtherNABP
NC3434139OtherNABP