Provider Demographics
NPI:1669893079
Name:4TH AVE PHARMACY INC.
Entity type:Organization
Organization Name:4TH AVE PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIUQE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-372-1023
Mailing Address - Street 1:5002 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1814
Mailing Address - Country:US
Mailing Address - Phone:718-492-1500
Mailing Address - Fax:718-492-4028
Practice Address - Street 1:5002 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1814
Practice Address - Country:US
Practice Address - Phone:718-492-1500
Practice Address - Fax:718-492-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0323683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7061770001Medicare NSC