1962510347 NPI number — VICTORY DISTRIBUTORS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962510347 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:
1962510347
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:
35 MANCHESTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03038-3064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-421-2596
Provider Business Practice Location Address Fax Number:
603-421-2730
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: 0669P , 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: 30703598 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2053795 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3080808 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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