Provider Demographics
NPI:1972660595
Name:DOROTHY HARRIS
Entity Type:Organization
Organization Name:DOROTHY HARRIS
Other - Org Name:PINE BLUFF OPTICAL COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-534-8184
Mailing Address - Street 1:3073 W 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4802
Mailing Address - Country:US
Mailing Address - Phone:870-534-8184
Mailing Address - Fax:870-534-8184
Practice Address - Street 1:3073 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4802
Practice Address - Country:US
Practice Address - Phone:870-534-8184
Practice Address - Fax:870-534-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL8837332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48776OtherBLUE CROSS BLUE SHIELD
AR4771310001Medicare ID - Type Unspecified