Provider Demographics
NPI:1578881975
Name:MEDINA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EAST HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770
Mailing Address - Country:US
Mailing Address - Phone:605-867-3048
Mailing Address - Fax:
Practice Address - Street 1:EAST HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-3048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60040238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist