Provider Demographics
NPI:1003022773
Name:EDMOND OPTICAL SHOP, INC.
Entity Type:Organization
Organization Name:EDMOND OPTICAL SHOP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNEROPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-341-6588
Mailing Address - Street 1:920 S BRYANT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5797
Mailing Address - Country:US
Mailing Address - Phone:405-341-6588
Mailing Address - Fax:405-348-9537
Practice Address - Street 1:920 S BRYANT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5797
Practice Address - Country:US
Practice Address - Phone:405-341-6588
Practice Address - Fax:405-348-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0699470001Medicare NSC