Provider Demographics
NPI:1295741841
Name:VICTORY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:VICTORY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS PHARMD
Authorized Official - Phone:718-567-1203
Mailing Address - Street 1:699 92ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3619
Mailing Address - Country:US
Mailing Address - Phone:718-567-1203
Mailing Address - Fax:718-567-1438
Practice Address - Street 1:699 92ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-3619
Practice Address - Country:US
Practice Address - Phone:718-567-1203
Practice Address - Fax:718-567-1438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X, 333600000X
NY0098683336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3349695OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY01196318Medicaid
NY00243449Medicaid