Healthcare Provider Details

I. General information

NPI: 1285943829
Provider Name (Legal Business Name): VICTORY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 E WILLIAM ST
DECATUR IL
62521-1528
US

IV. Provider business mailing address

163 N WATER ST
DECATUR IL
62523-1309
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-1000
  • Fax: 217-422-2658
Mailing address:
  • Phone: 217-428-4000
  • Fax: 217-429-8651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. WOLE K ADEOYE
Title or Position: PRESIDENT
Credential: R.PH
Phone: 217-428-4000