Provider Demographics
NPI:1780620658
Name:VICTORY PHARMACY
Entity type:Organization
Organization Name:VICTORY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICOTR
Authorized Official - Middle Name:
Authorized Official - Last Name:BERAJA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:702-893-9361
Mailing Address - Street 1:4161 S EASTERN AVE
Mailing Address - Street 2:A3
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5484
Mailing Address - Country:US
Mailing Address - Phone:702-893-9361
Mailing Address - Fax:702-893-9364
Practice Address - Street 1:4161 S EASTERN AVE
Practice Address - Street 2:A3
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5484
Practice Address - Country:US
Practice Address - Phone:702-893-9361
Practice Address - Fax:702-893-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH02108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2989347OtherNCPDP
NV5713320001Medicare NSC