Provider Demographics
NPI:1497763197
Name:ROLLE, LARRY T (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:T
Last Name:ROLLE
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 1:145 RUE VUE DU LAC
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1543
Mailing Address - Country:US
Mailing Address - Phone:309-699-9999
Mailing Address - Fax:
Practice Address - Street 1:411 MARTIN LUTHER KING DR.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-497-0790
Practice Address - Fax:309-497-3567
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist