Provider Demographics
NPI:1134716186
Name:SIEGEL, JERRY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 LYTTON WAY
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3331
Mailing Address - Country:US
Mailing Address - Phone:614-783-8582
Mailing Address - Fax:
Practice Address - Street 1:8467 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-4707
Practice Address - Country:US
Practice Address - Phone:614-863-2000
Practice Address - Fax:614-863-2000
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03311879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist