Healthcare Provider Details

I. General information

NPI: 1053636498
Provider Name (Legal Business Name): HOLLY LYNN KOFFLER RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

IV. Provider business mailing address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

V. Phone/Fax

Practice location:
  • Phone: 718-616-5800
  • Fax:
Mailing address:
  • Phone: 718-616-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20 035169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: