Healthcare Provider Details

I. General information

NPI: 1154028520
Provider Name (Legal Business Name): MANZAN G KOFFI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 N STATE LINE AVE
TEXARKANA AR
71854-1935
US

IV. Provider business mailing address

6210 GIBSON LN APT 5306
TEXARKANA TX
75503-1256
US

V. Phone/Fax

Practice location:
  • Phone: 870-772-0236
  • Fax:
Mailing address:
  • Phone: 682-217-0275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD16429
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: