Provider Demographics
NPI:1073607230
Name:OPTICAL SHOP INC
Entity Type:Organization
Organization Name:OPTICAL SHOP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-937-2399
Mailing Address - Street 1:223 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1952
Mailing Address - Country:US
Mailing Address - Phone:636-937-2399
Mailing Address - Fax:636-937-4683
Practice Address - Street 1:223 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1952
Practice Address - Country:US
Practice Address - Phone:636-937-2399
Practice Address - Fax:636-937-4683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12545597332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO321354102Medicaid