Provider Demographics
NPI:1083603385
Name:FORMICA OPTICAL
Entity Type:Organization
Organization Name:FORMICA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-443-6508
Mailing Address - Street 1:110 REVCO RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-7726
Mailing Address - Country:US
Mailing Address - Phone:814-443-6508
Mailing Address - Fax:814-443-0590
Practice Address - Street 1:110 REVCO RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-7726
Practice Address - Country:US
Practice Address - Phone:814-443-6508
Practice Address - Fax:814-443-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012176490001Medicaid
PA0012176490001Medicaid