Provider Demographics
NPI:1477239986
Name:ROQUE, JOSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ROQUE
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 1:617 S LAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1222
Mailing Address - Country:US
Mailing Address - Phone:414-418-3329
Mailing Address - Fax:
Practice Address - Street 1:2600 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1926
Practice Address - Country:US
Practice Address - Phone:414-545-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2214240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist