Provider Demographics
NPI:1689707804
Name:SAM'S CLUB OPTICAL
Entity Type:Organization
Organization Name:SAM'S CLUB OPTICAL
Other - Org Name:SAM'S CLUB OPTICAL 30-8192
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MPI ASSOCIATE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-1703
Mailing Address - Street 1:702 SW 8TH ST
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:479-277-1703
Mailing Address - Fax:
Practice Address - Street 1:3440 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2525
Practice Address - Country:US
Practice Address - Phone:334-671-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty