Provider Demographics
NPI:1316581978
Name:GRENOLDS, LUCAS GERALD
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:GERALD
Last Name:GRENOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7809 CALIBRE CROSSING DR APT 207
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7756
Mailing Address - Country:US
Mailing Address - Phone:716-367-8753
Mailing Address - Fax:
Practice Address - Street 1:900 METROPOLITAN AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3262
Practice Address - Country:US
Practice Address - Phone:704-973-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist