Provider Demographics
NPI:1750658480
Name:SOBOCINSKI, GARY FRANK (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:FRANK
Last Name:SOBOCINSKI
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 1:3274 BRIDGEPORT PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3344
Mailing Address - Country:US
Mailing Address - Phone:314-770-0440
Mailing Address - Fax:
Practice Address - Street 1:4033 SOVEREIGN COURT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:314-369-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0029437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist