Provider Demographics
NPI:1104651033
Name:COFFEE, SPENCER WILLIAM
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:WILLIAM
Last Name:COFFEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6304
Mailing Address - Country:US
Mailing Address - Phone:708-354-4441
Mailing Address - Fax:
Practice Address - Street 1:210 W 7TH ST STE B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2903
Practice Address - Country:US
Practice Address - Phone:512-893-5000
Practice Address - Fax:512-229-0795
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist