MEDICARE: MR. MARK WILLIAM LAQUE RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	044450	NY

General Provider Information

NPI Number	:	1275651754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK WILLIAM LAQUE RPH

Provider Business Mailing Address
First Line	:	2949 ERIE BLVD E
Second Line	:	SUITE 103
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1442
Country	:	US
Telephone Number	:	800-270-0444
Fax Number	:

Provider Business Practice Location Address
First Line	:	2949 ERIE BLVD E
Second Line	:	SUITE 103
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1442
Country	:	US
Telephone Number	:	315-425-8028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	02/21/2008

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