Provider Demographics
NPI:1356696892
Name:AGYEN, KOFI
Entity type:Individual
Prefix:MR
First Name:KOFI
Middle Name:
Last Name:AGYEN
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 1:11414 CYPRESS BAY ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7368
Mailing Address - Country:US
Mailing Address - Phone:407-222-4401
Mailing Address - Fax:
Practice Address - Street 1:8337 SOUTHPARK CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9049
Practice Address - Country:US
Practice Address - Phone:497-345-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist