Provider Demographics
NPI:1003075987
Name:RED'S SHOE BARN, INC.
Entity Type:Organization
Organization Name:RED'S SHOE BARN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-742-1893
Mailing Address - Street 1:35 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3217
Mailing Address - Country:US
Mailing Address - Phone:603-742-1893
Mailing Address - Fax:603-742-9133
Practice Address - Street 1:35 BROADWAY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3217
Practice Address - Country:US
Practice Address - Phone:603-742-1893
Practice Address - Fax:603-742-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0807010001Medicare NSC