Provider Demographics
NPI:1477677623
Name:WALMAN OPTICAL COMPANY
Entity Type:Organization
Organization Name:WALMAN OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-520-6000
Mailing Address - Street 1:410 CENTRAL AVENUE
Mailing Address - Street 2:320 STRAIN BUILDING
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401
Mailing Address - Country:US
Mailing Address - Phone:406-761-2872
Mailing Address - Fax:406-761-8194
Practice Address - Street 1:410 CENTRAL AVENUE
Practice Address - Street 2:320 STRAIN BUILDING
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401
Practice Address - Country:US
Practice Address - Phone:406-761-2872
Practice Address - Fax:406-761-8194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5520019OtherCHIP PROVIDER NUMBER
MT0550043Medicaid