1851524342 NPI number — VICTORY DISTRIBUTORS, LLC

Table of content: (NPI 1851524342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851524342 NPI number — VICTORY DISTRIBUTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY DISTRIBUTORS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HANNAFORD FOOD & DRUG #191
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851524342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
MS3000
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04104-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-885-7454
Provider Business Mailing Address Fax Number:
207-396-2028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66-2 DRUM HILL SHOPPING CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHELMSFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-970-2001
Provider Business Practice Location Address Fax Number:
978-459-9026
Provider Enumeration Date:
08/31/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EATON
Authorized Official First Name:
ELWEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY INSURANCE SPECIALIST
Authorized Official Telephone Number:
207-885-7454

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2677 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)