Provider Demographics
NPI:1417981887
Name:LUCAS, TIMOTHY WADE (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WADE
Last Name:LUCAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 SUMMERS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8286
Mailing Address - Country:US
Mailing Address - Phone:540-966-4858
Mailing Address - Fax:540-992-3273
Practice Address - Street 1:40 SUMMERS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-8286
Practice Address - Country:US
Practice Address - Phone:540-966-4858
Practice Address - Fax:540-992-3273
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4316730001Medicare NSC