Provider Demographics
NPI:1922690635
Name:AMEGADJE, KOFFI AMEGBO
Entity Type:Individual
Prefix:DR
First Name:KOFFI
Middle Name:AMEGBO
Last Name:AMEGADJE
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 1:5202 MURFREESBORO RD
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-2714
Mailing Address - Country:US
Mailing Address - Phone:615-793-3784
Mailing Address - Fax:
Practice Address - Street 1:5202 MURFREESBORO RD
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-2714
Practice Address - Country:US
Practice Address - Phone:615-793-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist