Provider Demographics
NPI:1760757397
Name:MARK, VICTOR (RPH)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:MARK
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 1:215 ROBIN REDBREAST RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-4121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 CENTER BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3221
Practice Address - Country:US
Practice Address - Phone:302-894-0250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0002124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist