Provider Demographics
NPI:1811598485
Name:AMANQUAH, KOFI
Entity Type:Individual
Prefix:
First Name:KOFI
Middle Name:
Last Name:AMANQUAH
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 1:11900 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2920
Mailing Address - Country:US
Mailing Address - Phone:904-641-1551
Mailing Address - Fax:904-641-7320
Practice Address - Street 1:11900 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2920
Practice Address - Country:US
Practice Address - Phone:904-641-1551
Practice Address - Fax:904-641-7320
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist