Healthcare Provider Details

I. General information

NPI: 1891399861
Provider Name (Legal Business Name): LUCAS RUSSELL GROENEVELD PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WAINWRIGHT DR
WALLA WALLA WA
99362-3994
US

IV. Provider business mailing address

610 BALM ST
WALLA WALLA WA
99362-3373
US

V. Phone/Fax

Practice location:
  • Phone: 509-525-5200
  • Fax:
Mailing address:
  • Phone: 515-868-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number23728
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: