Provider Demographics
NPI:1982741377
Name:KOCH PHARMACY CORP
Entity Type:Organization
Organization Name:KOCH PHARMACY CORP
Other - Org Name:ELKOCH PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:ABU
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-381-0120
Mailing Address - Street 1:126 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4308
Mailing Address - Country:US
Mailing Address - Phone:718-381-0120
Mailing Address - Fax:718-381-5780
Practice Address - Street 1:126 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4308
Practice Address - Country:US
Practice Address - Phone:718-381-0120
Practice Address - Fax:718-381-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025408333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02248873Medicaid
NY02248873Medicaid