Provider Demographics
NPI:1205312261
Name:BARRANCO MEDINA, SERGIO
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:
Last Name:BARRANCO 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 1:10275 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1115
Mailing Address - Country:US
Mailing Address - Phone:314-477-4532
Mailing Address - Fax:
Practice Address - Street 1:3171 RIVERPORT TECH CENTER DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-4825
Practice Address - Country:US
Practice Address - Phone:314-627-6121
Practice Address - Fax:314-983-0143
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist