MEDICARE: SISKIN'S SAN CARLOS PHARMACY INC

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
2	333600000X	Pharmacy	PHY32600	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0585933	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1013001429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SISKIN'S SAN CARLOS PHARMACY INC

Provider Business Mailing Address
First Line	:	825 LAUREL ST
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-3914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 LAUREL ST
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-3914
Country	:	US
Telephone Number	:	650-591-9636
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT SISKIN
Credential	:
Telephone Number	:	650-591-9636

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/24/2007

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