Provider Demographics
NPI:1104835891
Name:THE FOOTWORKS STORE INC.
Entity type:Organization
Organization Name:THE FOOTWORKS STORE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED
Authorized Official - Phone:614-367-1510
Mailing Address - Street 1:1302 HILL RD N
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-0000
Mailing Address - Country:US
Mailing Address - Phone:614-367-1510
Mailing Address - Fax:614-367-1246
Practice Address - Street 1:1302 HILL RD N
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-0000
Practice Address - Country:US
Practice Address - Phone:614-367-1510
Practice Address - Fax:614-367-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH317250OtherBC/BS
OH317250OtherBC/BS