Provider Demographics
NPI:1982121695
Name:GAVIN, WILLIAM LUCAS (RPH)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LUCAS
Last Name:GAVIN
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 1:21 PELHAM DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-1218
Mailing Address - Country:US
Mailing Address - Phone:518-847-2348
Mailing Address - Fax:
Practice Address - Street 1:5360 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-3596
Practice Address - Country:US
Practice Address - Phone:716-646-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist