Provider Demographics
NPI:1609009737
Name:VICTORY DISTRIBUTORS, LLC
Entity Type:Organization
Organization Name:VICTORY DISTRIBUTORS, LLC
Other - Org Name:HANNAFORD SUPERMARKET & PHARMACY #8436
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS 3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-885-3121
Practice Address - Street 1:7 KILTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6522
Practice Address - Country:US
Practice Address - Phone:603-622-2320
Practice Address - Fax:603-625-6240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0345-P332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3004570OtherNCPDP PROVIDER NUMBER
NH30707673Medicaid
3004570OtherNCPDP PROVIDER NUMBER
0019458Medicare PIN