Provider Demographics
NPI:1083657050
Name:SPEC SHOPPE
Entity Type:Organization
Organization Name:SPEC SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FARNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-582-8911
Mailing Address - Street 1:1713 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2613
Mailing Address - Country:US
Mailing Address - Phone:660-582-8911
Mailing Address - Fax:660-582-2545
Practice Address - Street 1:1713 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468
Practice Address - Country:US
Practice Address - Phone:660-582-8911
Practice Address - Fax:660-582-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO322223405Medicaid
MO0904620001Medicare NSC