Provider Demographics
NPI:1710933833
Name:VIC VENA PHARMACY, INC
Entity Type:Organization
Organization Name:VIC VENA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:VENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-372-7761
Mailing Address - Street 1:1322 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2036
Mailing Address - Country:US
Mailing Address - Phone:716-372-7761
Mailing Address - Fax:716-372-4525
Practice Address - Street 1:1322 W STATE ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2036
Practice Address - Country:US
Practice Address - Phone:716-372-7761
Practice Address - Fax:716-372-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY018816333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00916596Medicaid
NY00916596Medicaid