# GIBSON PHARMACY OF GRENADA, INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Gibson Pharmacy
- **Organization subpart:** No

## Provider details

- **NPI number:** 1861533820
- **Authorized official:** MR. FRED S FORTENBERRY RPH (PRES)
- **Authorized official phone:** (662) 226-6589

## Contact information

- **Practice address:** 710 LAKEVIEW DR, GRENADA, MS 38901-4346
- **Practice address phone:** (662) 226-6589
- **Practice address fax:** (662) 226-1604
- **Mailing address:** 710 LAKEVIEW DR, GRENADA, MS 38901-4346
- **Mailing address phone:** (662) 226-6589
- **Mailing address fax:** (662) 226-1604

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | 00662 | MS | Yes |

## Other

- **Enumeration date:** 02/10/2007
- **Last updated:** 08/22/2020