Provider Demographics
NPI:1821135468
Name:ROQUE, JORGE
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:ROQUE
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:PENA POBRE PARCELAS
Mailing Address - Street 2:HC-01 BOX 4646
Mailing Address - City:NAGUABO
Mailing Address - State:PR
Mailing Address - Zip Code:00718-4646
Mailing Address - Country:US
Mailing Address - Phone:787-874-1460
Mailing Address - Fax:
Practice Address - Street 1:CALLE MUNOZ RIVERA #17
Practice Address - Street 2:
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718-4646
Practice Address - Country:US
Practice Address - Phone:787-874-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4355183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician