Provider Demographics
NPI:1902084734
Name:FOOTPHARMACY DIRECT
Entity Type:Organization
Organization Name:FOOTPHARMACY DIRECT
Other - Org Name:ORTHOTIC WORLD
Other - Org Type:Other Name
Authorized Official - Title/Position:SALES MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:COS
Authorized Official - Phone:800-860-2773
Mailing Address - Street 1:906 W MCDERMOTT DR
Mailing Address - Street 2:STE.116-312
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6510
Mailing Address - Country:US
Mailing Address - Phone:800-860-2773
Mailing Address - Fax:469-675-0831
Practice Address - Street 1:906 W MCDERMOTT DR
Practice Address - Street 2:STE.116-312
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6510
Practice Address - Country:US
Practice Address - Phone:800-860-2773
Practice Address - Fax:469-675-0831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPED-3-008335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
519675848OtherUNITED HEALTH CARE
90079283OtherBCBS