Provider Demographics
NPI:1770705824
Name:WILLIS, KANDY KAYE (RPH)
Entity type:Individual
Prefix:
First Name:KANDY
Middle Name:KAYE
Last Name:WILLIS
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:RR 1
Mailing Address - Street 2:BOX 89B
Mailing Address - City:CAVE IN ROCK
Mailing Address - State:IL
Mailing Address - Zip Code:62919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:#6 FERRELL ROAD
Practice Address - Street 2:
Practice Address - City:ROSICLARE
Practice Address - State:IL
Practice Address - Zip Code:62982
Practice Address - Country:US
Practice Address - Phone:618-285-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist