Provider Demographics
NPI:1083906069
Name:VICTORIA, CYNTHIA LOUISE (RPH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LOUISE
Last Name:VICTORIA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4879 CHARLTON LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3376
Mailing Address - Country:US
Mailing Address - Phone:704-582-1189
Mailing Address - Fax:
Practice Address - Street 1:6701 MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5000
Practice Address - Country:US
Practice Address - Phone:704-364-9043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20288183500000X
SC12883183500000X
NY047319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist