Healthcare Provider Details

I. General information

NPI: 1578428041
Provider Name (Legal Business Name): KINGSLEY SEFA BOAKYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 WILLIAMSBRIDGE RD
BRONX NY
10461-1605
US

IV. Provider business mailing address

1171 CLAY AVE APT 2S
BRONX NY
10456-4215
US

V. Phone/Fax

Practice location:
  • Phone: 718-239-7569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number073520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: