Provider Demographics
NPI:1669757183
Name:BOSSMAN, EMMANUEL KOFI (MS PHARM)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:KOFI
Last Name:BOSSMAN
Suffix:
Gender:M
Credentials:MS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15500 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-1839
Mailing Address - Country:US
Mailing Address - Phone:510-483-3917
Mailing Address - Fax:510-483-8278
Practice Address - Street 1:15500 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94579-1839
Practice Address - Country:US
Practice Address - Phone:510-483-3917
Practice Address - Fax:510-483-8278
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 59609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist