MEDICARE: RIDGE COLONIAL LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	036463	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2176914	OTHER		PK

General Provider Information

NPI Number	:	1295231694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGE COLONIAL LLC

Provider Business Mailing Address
First Line	:	5723 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3815
Country	:	US
Telephone Number	:	718-439-5000
Fax Number	:	718-439-5003

Provider Business Practice Location Address
First Line	:	5723 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3815
Country	:	US
Telephone Number	:	718-439-5000
Fax Number	:	718-439-5003

Authorized Official
Title or Position	:	OWNER
Name	:	MUHAMMAD SHAMS
Credential	:
Telephone Number	:	718-439-5000

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	04/25/2018

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