Provider Demographics
NPI:1568479871
Name:JOHNSON OPTICAL DISPENSARY
Entity Type:Organization
Organization Name:JOHNSON OPTICAL DISPENSARY
Other - Org Name:OKLAHOMA EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LABETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-477-1242
Mailing Address - Street 1:1003 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3119
Mailing Address - Country:US
Mailing Address - Phone:580-477-1242
Mailing Address - Fax:580-477-1249
Practice Address - Street 1:1003 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3119
Practice Address - Country:US
Practice Address - Phone:580-477-1242
Practice Address - Fax:580-477-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768860DMedicaid
OK100768860DMedicaid
OK=========002OtherBLUE CROSS BLUE SHIELD
OK0340470003Medicare NSC