Provider Demographics
NPI:1083849947
Name:SAM'S CLUB OPTICAL
Entity type:Organization
Organization Name:SAM'S CLUB OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CARRIER SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8320
Mailing Address - Street 1:702 SW 8TH STREET
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:
Mailing Address - Fax:
Practice Address - Street 1:735 SOUTHPARK BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3605
Practice Address - Country:US
Practice Address - Phone:804-520-0508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty