Provider Demographics
NPI:1568857134
Name:VANDER WEIDE, LUKE AARON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:AARON
Last Name:VANDER WEIDE
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 1:16811 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:#101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3404
Mailing Address - Country:US
Mailing Address - Phone:360-750-3206
Mailing Address - Fax:
Practice Address - Street 1:16811 SE MCGILLIVRAY BLVD
Practice Address - Street 2:#101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3404
Practice Address - Country:US
Practice Address - Phone:360-750-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03234108183500000X
WAPH605618141835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist