Provider Demographics
NPI:1558418152
Name:GORDON'S FAIRVIEW PHARMACY
Entity Type:Organization
Organization Name:GORDON'S FAIRVIEW PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAU
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:714-389-4826
Mailing Address - Street 1:2600 WALNUT AVE UNIT F
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7032
Mailing Address - Country:US
Mailing Address - Phone:714-389-4826
Mailing Address - Fax:714-389-4821
Practice Address - Street 1:2600 WALNUT AVE UNIT F
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7032
Practice Address - Country:US
Practice Address - Phone:714-389-4826
Practice Address - Fax:714-389-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46099333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY46099OtherPHARMACY LICENSE
0525494OtherNABP
CA1558418152Medicaid
CAPHA460990Medicaid
CAPHA460990Medicaid
CAPHY46099OtherPHARMACY LICENSE
5280060001Medicare NSC