Provider Demographics
NPI:1962890970
Name:KISSI, KWASI
Entity type:Individual
Prefix:
First Name:KWASI
Middle Name:
Last Name:KISSI
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 1:4005 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4620
Mailing Address - Country:US
Mailing Address - Phone:770-934-3585
Mailing Address - Fax:
Practice Address - Street 1:4005 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4620
Practice Address - Country:US
Practice Address - Phone:770-934-3585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-27
Last Update Date:2014-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist