Provider Demographics
NPI:1255449633
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:
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 1:182 SUMMER ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-1277
Practice Address - Country:US
Practice Address - Phone:781-585-1326
Practice Address - Fax:781-585-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MA34043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0497789Medicaid
2039544OtherPK
MA0497789Medicaid