Provider Demographics
NPI:1477689479
Name:VICTORA, GAYLORD EARL (RPH)
Entity Type:Individual
Prefix:
First Name:GAYLORD
Middle Name:EARL
Last Name:VICTORA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 N TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50595-3026
Mailing Address - Country:US
Mailing Address - Phone:515-832-5284
Mailing Address - Fax:
Practice Address - Street 1:1602 EDGINGTON AVE
Practice Address - Street 2:
Practice Address - City:ELDORA
Practice Address - State:IA
Practice Address - Zip Code:50627-1626
Practice Address - Country:US
Practice Address - Phone:641-858-3567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA15091OtherIOWA PHARMACIST'S LICENSE