1902084734 NPI number — FOOTPHARMACY DIRECT

Table of content: (NPI 1902084734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902084734 NPI number — FOOTPHARMACY DIRECT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTPHARMACY DIRECT
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:
ORTHOTIC WORLD
Provider Other Organization Name Type Code:
5
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:
1902084734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
906 W MCDERMOTT DR
Provider Second Line Business Mailing Address:
STE.116-312
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-6510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-860-2773
Provider Business Mailing Address Fax Number:
469-675-0831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
906 W MCDERMOTT DR
Provider Second Line Business Practice Location Address:
STE.116-312
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75013-6510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-860-2773
Provider Business Practice Location Address Fax Number:
469-675-0831
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PENNINGTON
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
SALES MANAGER
Authorized Official Telephone Number:
800-860-2773

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CPED-3-008 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 519675848 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 90079283 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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