Provider Demographics
NPI:1740504570
Name:LAQUE, SUSAN (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LAQUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1303
Mailing Address - Country:US
Mailing Address - Phone:315-487-1585
Mailing Address - Fax:315-487-1916
Practice Address - Street 1:3325 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1303
Practice Address - Country:US
Practice Address - Phone:315-487-1585
Practice Address - Fax:315-487-1916
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist