Provider Demographics
NPI:1114492725
Name:BACKUS, KANDIS VECHELLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KANDIS
Middle Name:VECHELLE
Last Name:BACKUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KANDIS
Other - Middle Name:VECHELLE
Other - Last Name:BACKUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KNIGHT
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-815-3272
Practice Address - Fax:601-815-3123
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-152251835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care