Provider Demographics
NPI:1013389337
Name:ROQUE, KYLE EMANUEL (DR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:EMANUEL
Last Name:ROQUE
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ROGUE DR
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-4365
Mailing Address - Country:US
Mailing Address - Phone:508-493-7311
Mailing Address - Fax:
Practice Address - Street 1:1103 KEMPTON ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-1530
Practice Address - Country:US
Practice Address - Phone:508-990-3765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH236237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist