Provider Demographics
NPI:1346881851
Name:AMEVOR, EDEM KOFFI
Entity Type:Individual
Prefix:
First Name:EDEM
Middle Name:KOFFI
Last Name:AMEVOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 S VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4217
Mailing Address - Country:US
Mailing Address - Phone:801-486-8477
Mailing Address - Fax:
Practice Address - Street 1:3215 S VALLEY ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4217
Practice Address - Country:US
Practice Address - Phone:801-486-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-05
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6432485-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty