Provider Demographics
NPI:1427425834
Name:MEDINA, GIAN CARLO
Entity type:Individual
Prefix:
First Name:GIAN CARLO
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 1:610 GATEWAY CENTER WAY # A-E
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4533
Mailing Address - Country:US
Mailing Address - Phone:619-262-4373
Mailing Address - Fax:
Practice Address - Street 1:610 GATEWAY CENTER WAY # A-E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4533
Practice Address - Country:US
Practice Address - Phone:619-262-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist