Provider Demographics
NPI:1407995491
Name:SICILIANO, JOHN ANTHONY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:SICILIANO
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 1:9518 NEW GALEN RD
Mailing Address - Street 2:
Mailing Address - City:COHOCTON
Mailing Address - State:NY
Mailing Address - Zip Code:14826-9772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5975 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:585-346-5615
Practice Address - Fax:585-346-2212
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038348-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist