Provider Demographics
NPI:1952687345
Name:KOFFI, LISE MYRIAM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:MYRIAM
Last Name:KOFFI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 MLK JR HWY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4201
Mailing Address - Country:US
Mailing Address - Phone:301-955-0108
Mailing Address - Fax:301-955-0108
Practice Address - Street 1:10401 MLK JR HWY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4201
Practice Address - Country:US
Practice Address - Phone:301-955-0108
Practice Address - Fax:301-955-0108
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist