Provider Demographics
NPI:1235126038
Name:VICTORY DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:VICTORY DISCOUNT PHARMACY INC
Other - Org Name:VICTORY DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:YASSINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-752-9888
Mailing Address - Street 1:12922 VICTORY BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2924
Mailing Address - Country:US
Mailing Address - Phone:818-752-9888
Mailing Address - Fax:818-752-0492
Practice Address - Street 1:12922 VICTORY BLVD
Practice Address - Street 2:STE A
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2924
Practice Address - Country:US
Practice Address - Phone:818-752-9888
Practice Address - Fax:818-752-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY414463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0532641OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA414460Medicaid
CA1102470001Medicare NSC