Healthcare Provider Details

I. General information

NPI: 1205312261
Provider Name (Legal Business Name): DR. SERGIO BARRANCO MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 RIVERPORT TECH CENTER DR
MARYLAND HEIGHTS MO
63043-4825
US

IV. Provider business mailing address

10275 CLAYTON RD
SAINT LOUIS MO
63124-1115
US

V. Phone/Fax

Practice location:
  • Phone: 314-627-6121
  • Fax: 314-983-0143
Mailing address:
  • Phone: 314-477-4532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2016019830
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: