Provider Demographics
NPI:1861003477
Name:HUTSON, GAVIN W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:W
Last Name:HUTSON
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 1:2112 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4277
Mailing Address - Country:US
Mailing Address - Phone:773-761-3006
Mailing Address - Fax:
Practice Address - Street 1:2112 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4277
Practice Address - Country:US
Practice Address - Phone:773-761-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032046183500000X
IL051.303956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist