Provider Demographics
NPI:1629136734
Name:J & R OPTICAL
Entity Type:Organization
Organization Name:J & R OPTICAL
Other - Org Name:ODOM'S OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-977-0272
Mailing Address - Street 1:1461 CANTON MART RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5413
Mailing Address - Country:US
Mailing Address - Phone:601-977-0272
Mailing Address - Fax:601-977-0689
Practice Address - Street 1:1461 CANTON MART RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5413
Practice Address - Country:US
Practice Address - Phone:601-977-0272
Practice Address - Fax:601-977-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0531900002Medicare NSC