Provider Demographics
NPI:1265855753
Name:LEE, GAVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:LEE
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 1:30019 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5434
Mailing Address - Country:US
Mailing Address - Phone:310-377-6829
Mailing Address - Fax:
Practice Address - Street 1:30019 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90275-5434
Practice Address - Country:US
Practice Address - Phone:310-377-6829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist