MEDICARE: PHILIP PENG

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	183500000X	Pharmacist	044226	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	044226	OTHER	NY	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1861672289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP PENG

Provider Business Mailing Address
First Line	:	831 58TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5218 8TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-2816
Country	:	US
Telephone Number	:	718-686-0812
Fax Number	:	718-686-0811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	11/14/2007

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Directions to “ PHILIP PENG ” Practice Location

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