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NPI Code Detail

MEDICARE: VICTORY DISTRIBUTORS, LLC

MEDICARE: VICTORY DISTRIBUTORS, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical Supplies0398-PNH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
13061176OTHERNCPDP PROVIDER NUMBER
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053544841
Entity Type Code : Organization
Provider Name (Legal Business Name) : VICTORY DISTRIBUTORS, LLC
Provider Business Mailing Address
First Line : PO BOX 1000
Second Line : MS3000
City : PORTLAND
State : ME
Zip : 04104-5005
Country : US
Telephone Number : 207-885-7454
Fax Number : 207-885-3121
Provider Business Practice Location Address
First Line : 73 FORT EDDY RD
Second Line :
City : CONCORD
State : NH
Zip : 03301-7405
Country : US
Telephone Number : 603-228-2121
Fax Number : 603-223-9702
Authorized Official
Title or Position : PHARMACY INSURANCE SPECIALIST
Name : ELWEN EATON
Credential :
Telephone Number : 207-885-7454
Provider Enumeration Date : 08/27/2009
Last Update Date : 11/18/2014

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