Healthcare Provider Details

I. General information

NPI: 1982741377
Provider Name (Legal Business Name): KOCH PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 WYCKOFF AVE
BROOKLYN NY
11237-4308
US

IV. Provider business mailing address

126 WYCKOFF AVE
BROOKLYN NY
11237-4308
US

V. Phone/Fax

Practice location:
  • Phone: 718-381-0120
  • Fax: 718-381-5780
Mailing address:
  • Phone: 718-381-0120
  • Fax: 718-381-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number025408
License Number StateNY

VIII. Authorized Official

Name: MR. ABU J SIDDIQUE
Title or Position: VICE PRESIDENT DIRECTOR OF PHARMACY
Credential: RPH
Phone: 718-381-0120