Healthcare Provider Details

I. General information

NPI: 1265191118
Provider Name (Legal Business Name): VICTAPHARM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

IV. Provider business mailing address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

V. Phone/Fax

Practice location:
  • Phone: 401-300-5757
  • Fax:
Mailing address:
  • Phone: 401-300-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: LISA A PETERSON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 401-432-6029