Provider Demographics
NPI:1306014345
Name:SHARONA OPTICAL
Entity Type:Organization
Organization Name:SHARONA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-953-3339
Mailing Address - Street 1:18325 N ALLIED WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-3105
Mailing Address - Country:US
Mailing Address - Phone:602-467-4966
Mailing Address - Fax:
Practice Address - Street 1:18325 N ALLIED WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-3105
Practice Address - Country:US
Practice Address - Phone:602-467-4966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HORIZON EYE SPECIALISTS & LASIK CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0629780001Medicare NSC