Provider Demographics
NPI:1538441654
Name:GIBBENS, MARC (PD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:GIBBENS
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3128 TRADITION AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0339
Mailing Address - Country:US
Mailing Address - Phone:225-769-0890
Mailing Address - Fax:225-757-1393
Practice Address - Street 1:3384 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5628
Practice Address - Country:US
Practice Address - Phone:225-387-5600
Practice Address - Fax:225-387-5628
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist