1578796603 NPI number — VICTORY DISTRIBUTORS, LLC

Table of content: (NPI 1578796603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578796603 NPI number — VICTORY DISTRIBUTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY DISTRIBUTORS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HANNAFORD FOOD & DRUG #8164
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578796603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
MS3000
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04104-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-885-7454
Provider Business Mailing Address Fax Number:
207-885-3121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 JOHN DEVINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03103-4034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-626-1233
Provider Business Practice Location Address Fax Number:
603-626-3002
Provider Enumeration Date:
08/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EATON
Authorized Official First Name:
ELWEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY INSURANCE SPECIALIST
Authorized Official Telephone Number:
207-885-7454

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0366-P , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30707665 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3004809 . This is a "NCPDP PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




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