Provider Demographics
NPI:1285250985
Name:KONAN, KOUAKOU
Entity type:Individual
Prefix:
First Name:KOUAKOU
Middle Name:
Last Name:KONAN
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 1:15300 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3261
Mailing Address - Country:US
Mailing Address - Phone:734-283-9500
Mailing Address - Fax:734-283-2248
Practice Address - Street 1:15300 EUREKA RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3261
Practice Address - Country:US
Practice Address - Phone:734-283-9500
Practice Address - Fax:734-283-2248
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020377431835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist