Provider Demographics
NPI:1538760830
Name:KUBENA COFFMAN, TRACY BROOKE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:BROOKE
Last Name:KUBENA COFFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 LONE FALCON LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-5146
Mailing Address - Country:US
Mailing Address - Phone:682-561-6148
Mailing Address - Fax:
Practice Address - Street 1:8621 OHIO DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2264
Practice Address - Country:US
Practice Address - Phone:469-633-0041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist