Healthcare Provider Details

I. General information

NPI: 1821241704
Provider Name (Legal Business Name): MILAN MICHAEL SIVACEK R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2008
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CROOKED HILL RD
BRENTWOOD NY
11717-1019
US

IV. Provider business mailing address

84 STOOTHOFF RD
EAST NORTHPORT NY
11731-3920
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-2295
  • Fax: 631-761-2298
Mailing address:
  • Phone: 631-368-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number029340
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: