Basic Information
| Provider Information | |||||||||
| NPI: | 1528694841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILES | ||||||||
| FirstName: | GAVIN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 N 40TH ST APT 27 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850187158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576200163 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 E INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2020 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | S024134 | AZ | Y |
No ID Information.