MEDICARE: VICTORY DISCOUNT PHARMACY INC

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
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY41446	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0532641	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235126038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY DISCOUNT PHARMACY INC

Provider Business Mailing Address
First Line	:	12922 VICTORY BLVD
Second Line	:	STE A
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91606-2924
Country	:	US
Telephone Number	:	818-752-9888
Fax Number	:	818-752-0492

Provider Business Practice Location Address
First Line	:	12922 VICTORY BLVD
Second Line	:	STE A
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91606-2924
Country	:	US
Telephone Number	:	818-752-9888
Fax Number	:	818-752-0492

Authorized Official
Title or Position	:	PIC AND PRESIDENT
Name	:	FARHAD YASSINI
Credential	:
Telephone Number	:	818-752-9888

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	09/17/2010

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Directions to “VICTORY DISCOUNT PHARMACY INC ” Practice Location

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