Provider Demographics
NPI:1902520240
Name:SUKA JR, EMMANUEL KOFI JR (PHARM D)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:KOFI
Last Name:SUKA JR
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 I-20 FRONTAGE RD APT K21
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-3525
Mailing Address - Country:US
Mailing Address - Phone:120-248-9113
Mailing Address - Fax:
Practice Address - Street 1:1435 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5170
Practice Address - Country:US
Practice Address - Phone:601-661-9652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-139531835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist