Provider Demographics
NPI:1861533820
Name:GIBSON PHARMACY OF GRENADA, INC
Entity type:Organization
Organization Name:GIBSON PHARMACY OF GRENADA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-226-6589
Mailing Address - Street 1:710 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4346
Mailing Address - Country:US
Mailing Address - Phone:662-226-6589
Mailing Address - Fax:662-226-1604
Practice Address - Street 1:710 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4346
Practice Address - Country:US
Practice Address - Phone:662-226-6589
Practice Address - Fax:662-226-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS006623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy