Provider Demographics
NPI:1255329405
Name:VICS FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:VICS FAMILY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:BPH
Authorized Official - Phone:208-465-7000
Mailing Address - Street 1:1513 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6008
Mailing Address - Country:US
Mailing Address - Phone:208-465-7000
Mailing Address - Fax:208-465-7091
Practice Address - Street 1:1513 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6008
Practice Address - Country:US
Practice Address - Phone:208-465-7000
Practice Address - Fax:208-465-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID800CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1304790OtherNABP
ID800CPOtherBOARD OF PHARMACY
ID804169900Medicaid
ID0295220001Medicare PIN
ID800CPOtherBOARD OF PHARMACY