Provider Demographics
NPI:1386182285
Name:GIBSON, DANTE (PHARMD)
Entity type:Individual
Prefix:
First Name:DANTE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36450 INLAND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9583
Mailing Address - Country:US
Mailing Address - Phone:866-370-1940
Mailing Address - Fax:
Practice Address - Street 1:36450 INLAND VALLEY DR
Practice Address - Street 2:SUITE #209
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9583
Practice Address - Country:US
Practice Address - Phone:866-370-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist