Provider Demographics
NPI:1265502348
Name:GAVIN HERBERT CO.
Entity Type:Organization
Organization Name:GAVIN HERBERT CO.
Other - Org Name:HORTON & CONVERSE HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LUMPKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-640-1231
Mailing Address - Street 1:PO BOX 9889
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-1889
Mailing Address - Country:US
Mailing Address - Phone:949-640-1231
Mailing Address - Fax:949-640-9123
Practice Address - Street 1:11600 WILSHIRE BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1773
Practice Address - Country:US
Practice Address - Phone:310-479-0960
Practice Address - Fax:310-477-3509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
CAPHY165953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1995613OtherPK
CAPHA165950Medicaid
CA0531060014Medicare NSC