Provider Demographics
NPI:1629590724
Name:O'BRIEN, GAVIN MAURICE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:MAURICE
Last Name:O'BRIEN
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 1:1300 HOSPITAL LOOP
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-8332
Mailing Address - Fax:
Practice Address - Street 1:PO BOX PH
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-8000
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0129975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist