1508974981 NPI number — VICTORY DISTRIBUTORS LLC

Table of content: (NPI 1508974981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508974981 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:
Provider Other Organization Name Type Code:
6
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:
1508974981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
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:
MS 3000
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:
704-645-6531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 COLISEUM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03063-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-889-6663
Provider Business Practice Location Address Fax Number:
603-594-9641
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAIL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND MANAGER
Authorized Official Telephone Number:
207-885-7454

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0476 , 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: 30008990 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3080811 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2053449 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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