Provider Demographics
NPI:1154886505
Name:LAROQUE, HOLLY (RPH)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LAROQUE
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 1:505 W VERNON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3767
Mailing Address - Country:US
Mailing Address - Phone:252-522-0353
Mailing Address - Fax:
Practice Address - Street 1:505 W VERNON AVE STE 100
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3767
Practice Address - Country:US
Practice Address - Phone:252-522-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3420635Medicaid
1548229933OtherNPI