Provider Demographics
NPI:1811273048
Name:KIVISTO, GAVIN HALL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:HALL
Last Name:KIVISTO
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 1:6852 VIA VERANO
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009
Mailing Address - Country:US
Mailing Address - Phone:760-539-7054
Mailing Address - Fax:
Practice Address - Street 1:6852 VIA VERANO
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-6021
Practice Address - Country:US
Practice Address - Phone:760-539-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54344183500000X
AZ12488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist