Provider Demographics
NPI:1073032843
Name:SIDDHIVINAYAK INC
Entity Type:Organization
Organization Name:SIDDHIVINAYAK INC
Other - Org Name:BERGEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RASIK
Authorized Official - Middle Name:M
Authorized Official - Last Name:NAGRECHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-972-1960
Mailing Address - Street 1:23 CANOE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-6121
Mailing Address - Country:US
Mailing Address - Phone:973-992-1951
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST STE 1600
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-1960
Practice Address - Fax:973-972-8158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIDDHIVINAYAK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00581900332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8172510Medicaid