Healthcare Provider Details

I. General information

NPI: 1588897078
Provider Name (Legal Business Name): VICTORY DISTRIBUTORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 BICENTENNIAL DRIVE
MANCHESTER NH
03104
US

IV. Provider business mailing address

PO BOX 1000 MS3000
PORTLAND ME
04104-5005
US

V. Phone/Fax

Practice location:
  • Phone: 603-644-2204
  • Fax: 603-666-0600
Mailing address:
  • Phone: 207-885-7454
  • Fax: 207-885-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0336-P
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier30707675
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer
# 2
Identifier3004556
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER NUMBER

VIII. Authorized Official

Name: ELWEN EATON
Title or Position: PHARMACY INSURANCE SPECIALIST
Credential:
Phone: 207-885-7454