Provider Demographics
NPI:1528070976
Name:VICTORY MEDICAL SUPPLY
Entity type:Organization
Organization Name:VICTORY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:IDIONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-552-8533
Mailing Address - Street 1:29350 SOUTHFIELD RD
Mailing Address - Street 2:STE 121
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2053
Mailing Address - Country:US
Mailing Address - Phone:248-552-8533
Mailing Address - Fax:248-552-7281
Practice Address - Street 1:29350 SOUTHFIELD RD
Practice Address - Street 2:STE 121
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2053
Practice Address - Country:US
Practice Address - Phone:248-552-8533
Practice Address - Fax:248-552-7281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4509852Medicaid
MI5716480001Medicare ID - Type Unspecified