Provider Demographics
NPI:1912258807
Name:VICTORY FAMILY PHARMACY, LLC
Entity Type:Organization
Organization Name:VICTORY FAMILY PHARMACY, LLC
Other - Org Name:THE APOTHECARY SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST / MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:718-448-0400
Mailing Address - Street 1:1975 VICTORY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3536
Mailing Address - Country:US
Mailing Address - Phone:718-448-0400
Mailing Address - Fax:718-448-0404
Practice Address - Street 1:1975 VICTORY BLVD STE A
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3536
Practice Address - Country:US
Practice Address - Phone:718-448-0400
Practice Address - Fax:718-448-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170316023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17 031602OtherLICENSE
NY17 031602OtherLICENSE