Provider Demographics
NPI:1174512537
Name:VICTORIA PHARMACY INC
Entity type:Organization
Organization Name:VICTORIA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:POND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:253-473-1919
Mailing Address - Street 1:PO BOX 9299
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98490-0299
Mailing Address - Country:US
Mailing Address - Phone:253-302-4178
Mailing Address - Fax:253-503-0858
Practice Address - Street 1:8001 S HOSMER ST
Practice Address - Street 2:SUITE C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-1017
Practice Address - Country:US
Practice Address - Phone:253-302-4178
Practice Address - Fax:253-503-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X, 333600000X
WACF000027833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4917590OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WA9056698Medicaid
WA6001333Medicaid
0509930002Medicare NSC