Provider Demographics
NPI:1093737967
Name:CONEY ISLAND HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:CONEY ISLAND HEALTH SERVICES, INC.
Other - Org Name:SAUL'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PERVEZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-265-9108
Mailing Address - Street 1:3514 MERMAID AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1508
Mailing Address - Country:US
Mailing Address - Phone:718-265-9108
Mailing Address - Fax:718-265-5327
Practice Address - Street 1:3514 MERMAID AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1508
Practice Address - Country:US
Practice Address - Phone:718-265-9108
Practice Address - Fax:718-265-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0225343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01572545Medicaid
NY1125180001Medicare NSC