=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902084734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOTPHARMACY DIRECT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2008
-----------------------------------------------------
Last Update Date | 01/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 906 W MCDERMOTT DR STE.116-312
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-6510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-860-2773
-----------------------------------------------------
Fax | 469-675-0831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 906 W MCDERMOTT DR STE.116-312
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-6510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-860-2773
-----------------------------------------------------
Fax | 469-675-0831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SALES MANAGER
-----------------------------------------------------
Name | MR. RANDALL LEE PENNINGTON
-----------------------------------------------------
Credential | C.O.S.
-----------------------------------------------------
Telephone | 800-860-2773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | CPED-3-008
-----------------------------------------------------
License Number State |
-----------------------------------------------------