Provider Demographics
NPI:1114026895
Name:GIBSON DRUG, INC
Entity type:Organization
Organization Name:GIBSON DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-743-5753
Mailing Address - Street 1:125 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WAKEENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67672
Mailing Address - Country:US
Mailing Address - Phone:785-743-5753
Mailing Address - Fax:
Practice Address - Street 1:125 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WAKEENEY
Practice Address - State:KS
Practice Address - Zip Code:67672
Practice Address - Country:US
Practice Address - Phone:785-743-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
KS108301533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100435710AMedicaid