Provider Demographics
NPI:1124367693
Name:LACKEY, GRANT DAVID (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:DAVID
Last Name:LACKEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 COHN VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5050
Mailing Address - Country:US
Mailing Address - Phone:916-204-0192
Mailing Address - Fax:
Practice Address - Street 1:131 COHN VALLEY WAY
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5050
Practice Address - Country:US
Practice Address - Phone:916-204-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434521835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist