Provider Demographics
NPI:1124494166
Name:GIBSON, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PARK CIRCLE DR APT B19
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7631
Mailing Address - Country:US
Mailing Address - Phone:228-238-9478
Mailing Address - Fax:
Practice Address - Street 1:1606 HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6917
Practice Address - Country:US
Practice Address - Phone:601-605-5928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-13947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist