Provider Demographics
NPI:1205972536
Name:SIDDIQUE, ABU J (RPH)
Entity type:Individual
Prefix:MR
First Name:ABU
Middle Name:J
Last Name:SIDDIQUE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:KOCH PHARMACY
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
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01294866Medicaid