Provider Demographics
NPI:1275651754
Name:LAQUE, MARK WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:LAQUE
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 1:2949 ERIE BLVD E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1442
Mailing Address - Country:US
Mailing Address - Phone:800-270-0444
Mailing Address - Fax:
Practice Address - Street 1:2949 ERIE BLVD E
Practice Address - Street 2:SUITE 103
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1442
Practice Address - Country:US
Practice Address - Phone:315-425-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist