Provider Demographics
NPI:1790855872
Name:GAVIN HERBERT COMPANY
Entity Type:Organization
Organization Name:GAVIN HERBERT COMPANY
Other - Org Name:HORTON AND CONVERSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
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:
Mailing Address - Fax:
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:213-481-7030
Practice Address - Fax:213-481-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X
CAPHY35468333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0596568OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA354680Medicaid
CAPHA354680Medicaid