MEDICARE: ULTIMATE FOOT STORE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GE-115-516-2112-01	OTHER	HI	GENERAL EXCISE TAX LICENSE

General Provider Information

NPI Number	:	1245706969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMATE FOOT STORE, INC

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

Provider Business Practice Location Address
First Line	:	820 W HIND DR STE 103
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96821-1849
Country	:	US
Telephone Number	:	808-542-0736
Fax Number	:	808-440-5251

Authorized Official
Title or Position	:	VP/TREASURER
Name	:	MR. DAVID R GRIFFITH
Credential	:
Telephone Number	:	808-542-0736

Provider Enumeration Date	:	10/19/2018
Last Update Date	:	09/09/2019

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Directions to “ULTIMATE FOOT STORE, INC ” Practice Location

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