Provider Demographics
NPI:1073134649
Name:VICTORY MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:VICTORY MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-770-0520
Mailing Address - Street 1:13894 S BANGERTER PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5320
Mailing Address - Country:US
Mailing Address - Phone:801-770-0520
Mailing Address - Fax:801-770-0922
Practice Address - Street 1:140 N 100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1735
Practice Address - Country:US
Practice Address - Phone:801-770-0520
Practice Address - Fax:801-770-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
626888500OtherDOL PROVIDER #