Provider Demographics
NPI:1508182254
Name:SIEJAK, JOHN RANDALL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:SIEJAK
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 1:726 EXCHANGE ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:726 EXCHANGE ST
Practice Address - Street 2:SUITE 310
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1484
Practice Address - Country:US
Practice Address - Phone:716-859-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist