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Provider Information for 1073621454


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VICTORY DISTRIBUTORS LLC

Other Names:  
Doing Business As: 
HANNAFORD SUPERMARKET & PHARMACY

Organization Subpart: NO

NPI: 1073621454
Last Updated: 2018-07-19
Certification Date:

Details

NameValue
NPI1073621454
Enumeration Date2006-08-27
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: MICHAEL VAIL
Title: President and Manager
Phone: 2078857454
Mailing Address PO BOX 1000
MS 3000
PORTLAND, ME 04104-5005
United States

Phone: 207-885-7454 | Fax:704-645-6531
 
Primary Practice Address 5 GILBERT ST
N BROOKFIELD, MA 01535-1409
United States

Phone: 508-867-4891 | Fax:508-867-4896
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDMA0409910
Other (non-Medicare)2039551PK
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyMA3417