Provider Demographics
NPI:1316070550
Name:VICTORY MEDICAL SUPPLY
Entity type:Organization
Organization Name:VICTORY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:MOYOSORE
Authorized Official - Last Name:OLAOFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-997-6968
Mailing Address - Street 1:6411 SEPULVEDA BLVD
Mailing Address - Street 2:STE 1J
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1304
Mailing Address - Country:US
Mailing Address - Phone:818-997-6968
Mailing Address - Fax:818-997-6946
Practice Address - Street 1:6411 SEPULVEDA BLVD
Practice Address - Street 2:STE 1J
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1304
Practice Address - Country:US
Practice Address - Phone:818-997-6968
Practice Address - Fax:818-997-6946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46843332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5947290001Medicare NSC