MEDICARE: SIDDIQUI CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	033394	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2151104	OTHER		PK

General Provider Information

NPI Number	:	1073907671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIDDIQUI CORPORATION

Provider Business Mailing Address
First Line	:	1109 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2305
Country	:	US
Telephone Number	:	718-434-4649
Fax Number	:	718-434-4168

Provider Business Practice Location Address
First Line	:	1109 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2305
Country	:	US
Telephone Number	:	718-434-4649
Fax Number	:	718-434-4168

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PERVEZ SIDDIQUI
Credential	:
Telephone Number	:	718-434-4649

Provider Enumeration Date	:	03/23/2015
Last Update Date	:	07/05/2016

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Directions to “SIDDIQUI CORPORATION ” Practice Location

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