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General NPI Number Information
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NPI Number | 1659041705
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Entity Type | Individual
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Provider Name | KAYLA MARIE ROQUE PHARMD
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Gender | Female
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Dates
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Enumeration Date | 09/19/2021
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Last Update Date | 09/19/2021
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Provider Practice Location Address
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Address Line | 794 MOUNT PROSPECT AVE
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City | NEWARK
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State | NJ
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Zip | 07104-3221
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Country | US
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Telephone | 973-483-4749
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Fax |
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Provider Business Mailing Address
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Address Line | 751 DEGRAW AVE
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City | NEWARK
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State | NJ
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Zip | 07104-1617
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Country | US
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Telephone | 862-596-4840
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 28RI04188900
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License Number State | NJ
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