Provider Demographics
NPI:1396835393
Name:SAM'S CLUB OPTICAL
Entity Type:Organization
Organization Name:SAM'S CLUB OPTICAL
Other - Org Name:SAM'S CLUB OPTICAL 30-6259
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NPI COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:EPPERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-788-5580
Mailing Address - Street 1:702 SW 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 SUNDANCE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-7935
Practice Address - Country:US
Practice Address - Phone:512-828-0534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear Supplier