Provider Demographics
NPI:1689887580
Name:BACK, DERONDA KAY (RPH)
Entity Type:Individual
Prefix:
First Name:DERONDA
Middle Name:KAY
Last Name:BACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 931
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0931
Mailing Address - Country:US
Mailing Address - Phone:606-666-7060
Mailing Address - Fax:606-666-9454
Practice Address - Street 1:842 HWY 15 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-7060
Practice Address - Fax:606-666-9454
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY008355OtherKY STATE LICENSE