Provider Demographics
NPI:1891026001
Name:SAM'S CLUB #4806
Entity Type:Organization
Organization Name:SAM'S CLUB #4806
Other - Org Name:SAM'S OPTICA #4806
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RETAIL BUSINESS STRATEGIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PABON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-653-8094
Mailing Address - Street 1:CARR#3 KM15.2
Mailing Address - Street 2:BO. CANOVANILLA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-474-7278
Mailing Address - Fax:787-757-4795
Practice Address - Street 1:CARR #3 KM 15.2
Practice Address - Street 2:BO. CANOVANILLA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-474-7278
Practice Address - Fax:787-757-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier