Provider Demographics
NPI:1104413954
Name:GIBSON, SUSAN L (PHARMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 LARGO LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5124
Mailing Address - Country:US
Mailing Address - Phone:859-312-0231
Mailing Address - Fax:
Practice Address - Street 1:402 RICHMOND RD N
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1133
Practice Address - Country:US
Practice Address - Phone:859-986-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist