Provider Demographics
NPI:1699283713
Name:GIBSON, ETHAN DWANE (PHARMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DWANE
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 1:1738 HAYMAKER PKWY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:270-590-0191
Mailing Address - Fax:
Practice Address - Street 1:118 E NEW CIRCLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-2115
Practice Address - Country:US
Practice Address - Phone:859-254-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY020779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist