Provider Demographics
NPI:1992295422
Name:VICTORY PHARMACY 2 PLLC
Entity type:Organization
Organization Name:VICTORY PHARMACY 2 PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:
Authorized Official - Last Name:AKUBUKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-608-4170
Mailing Address - Street 1:14601 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1621
Mailing Address - Country:US
Mailing Address - Phone:313-342-5051
Mailing Address - Fax:734-495-9555
Practice Address - Street 1:14601 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1621
Practice Address - Country:US
Practice Address - Phone:313-340-9799
Practice Address - Fax:313-340-9326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010113803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177240OtherPK
MI1992295422Medicaid