Provider Demographics
NPI:1487234621
Name:FOOTE, TRISTAN GERMANICUS
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:GERMANICUS
Last Name:FOOTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 HOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25637-1126
Mailing Address - Country:US
Mailing Address - Phone:304-239-2020
Mailing Address - Fax:
Practice Address - Street 1:164 HOLDEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT GAY
Practice Address - State:WV
Practice Address - Zip Code:25637-1126
Practice Address - Country:US
Practice Address - Phone:304-239-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0012429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist