Provider Demographics
NPI:1952882094
Name:DEFFO, TAMBOUE ESAIE (PHD,RPH)
Entity Type:Individual
Prefix:
First Name:TAMBOUE
Middle Name:ESAIE
Last Name:DEFFO
Suffix:
Gender:M
Credentials:PHD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 HALLET ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-5147
Mailing Address - Country:US
Mailing Address - Phone:913-575-3414
Mailing Address - Fax:
Practice Address - Street 1:13600 S ALDEN ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-5829
Practice Address - Country:US
Practice Address - Phone:913-539-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11652OtherPHARMACY LICENSE