Provider Demographics
NPI:1750604575
Name:STAVIN, GARY (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:STAVIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6320
Mailing Address - Country:US
Mailing Address - Phone:718-296-0400
Mailing Address - Fax:718-296-2815
Practice Address - Street 1:8007 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1902
Practice Address - Country:US
Practice Address - Phone:718-296-0400
Practice Address - Fax:718-296-2815
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02242419Medicaid