Provider Demographics
NPI:1922155027
Name:THE OPTICAL STORE
Entity Type:Organization
Organization Name:THE OPTICAL STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-874-4554
Mailing Address - Street 1:3750 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1002
Mailing Address - Country:US
Mailing Address - Phone:716-874-4554
Mailing Address - Fax:716-874-4555
Practice Address - Street 1:3750 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1002
Practice Address - Country:US
Practice Address - Phone:716-874-4554
Practice Address - Fax:716-874-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0646170001Medicare NSC