Provider Demographics
NPI:1639306921
Name:VANDERWOUDE, MICHAEL LOUIS (PHARM D, RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
Last Name:VANDERWOUDE
Suffix:
Gender:M
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 UNIVERSITY BLVD NE STE G
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1738
Mailing Address - Country:US
Mailing Address - Phone:505-272-3405
Mailing Address - Fax:505-272-8140
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006908183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist