1245706969 NPI number — ULTIMATE FOOT STORE, INC

Table of content: (NPI 1245706969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245706969 NPI number — ULTIMATE FOOT STORE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ULTIMATE FOOT STORE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245706969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 RICHARDS ST STE 525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96813-4623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-542-0736
Provider Business Mailing Address Fax Number:
808-440-5251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 W HIND DR STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96821-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-542-0736
Provider Business Practice Location Address Fax Number:
808-440-5251
Provider Enumeration Date:
10/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFITH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VP/TREASURER
Authorized Official Telephone Number:
808-542-0736

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GE-115-516-2112-01 . This is a "GENERAL EXCISE TAX LICENSE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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