Provider Demographics
NPI:1386715522
Name:VANDER BLEEK, LUKE (RPH)
Entity type:Individual
Prefix:MR
First Name:LUKE
Middle Name:
Last Name:VANDER BLEEK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:IL
Mailing Address - Zip Code:61270-2638
Mailing Address - Country:US
Mailing Address - Phone:815-772-3415
Mailing Address - Fax:815-772-7240
Practice Address - Street 1:124 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2638
Practice Address - Country:US
Practice Address - Phone:815-772-3415
Practice Address - Fax:815-772-7240
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBF5563350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363833823001Medicaid
IL363833823001Medicaid