Healthcare Provider Details

I. General information

NPI: 1730051608
Provider Name (Legal Business Name): CANDICE T PHILLIPS DRPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TEENA WILSON

II. Dates (important events)

Enumeration Date: 09/20/2025
Last Update Date: 09/20/2025
Certification Date: 09/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 E MONROE AVE
WEST MEMPHIS AR
72301-6032
US

IV. Provider business mailing address

2612 E MONROE AVE
WEST MEMPHIS AR
72301-6032
US

V. Phone/Fax

Practice location:
  • Phone: 901-352-8566
  • Fax:
Mailing address:
  • Phone: 901-352-8566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number105121
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number105121
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number908464201
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901552
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number2657421
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: