Provider Demographics
NPI:1710653001
Name:VANDERGON, LUCAS ROBERT
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:ROBERT
Last Name:VANDERGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8822 SHADYVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1490
Mailing Address - Country:US
Mailing Address - Phone:763-234-9730
Mailing Address - Fax:
Practice Address - Street 1:3255 VICKSBURG LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1317
Practice Address - Country:US
Practice Address - Phone:763-253-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist