Provider Demographics
NPI:1376203893
Name:KINBONG-KOFFI, HENDRETA (RPH)
Entity Type:Individual
Prefix:
First Name:HENDRETA
Middle Name:
Last Name:KINBONG-KOFFI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7665
Mailing Address - Country:US
Mailing Address - Phone:432-332-0908
Mailing Address - Fax:
Practice Address - Street 1:100 E UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7665
Practice Address - Country:US
Practice Address - Phone:432-332-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist