Provider Demographics
NPI:1619100740
Name:VICTORY DISTRIBUTORS, LLC
Entity type:Organization
Organization Name:VICTORY DISTRIBUTORS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-885-3121
Practice Address - Street 1:859 HANOVER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-5419
Practice Address - Country:US
Practice Address - Phone:603-627-4354
Practice Address - Fax:603-626-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0337-P332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30707674Medicaid
3004544OtherNCPDP PROVIDER NUMBER
0019458Medicare PIN
5474680015Medicare NSC