Provider Demographics
NPI:1194318303
Name:MONGRUE, LACEY
Entity type:Individual
Prefix:DR
First Name:LACEY
Middle Name:
Last Name:MONGRUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 RIVER WATCH PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2919
Mailing Address - Country:US
Mailing Address - Phone:706-210-0091
Mailing Address - Fax:706-228-5260
Practice Address - Street 1:3527 RIVER WATCH PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2919
Practice Address - Country:US
Practice Address - Phone:706-210-0091
Practice Address - Fax:706-228-5260
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist