Provider Demographics
NPI:1457188351
Name:KOUASSI, KOUASSI TATA (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KOUASSI
Middle Name:TATA
Last Name:KOUASSI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12767 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3211
Mailing Address - Country:US
Mailing Address - Phone:402-895-7037
Mailing Address - Fax:
Practice Address - Street 1:12767 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3211
Practice Address - Country:US
Practice Address - Phone:402-895-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist