Provider Demographics
NPI:1104948793
Name:PRECISION OPTICAL DISPENSARY, INC.
Entity type:Organization
Organization Name:PRECISION OPTICAL DISPENSARY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLYN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-825-1992
Mailing Address - Street 1:1490 WEST GOVERNMENT STREET SUITE 8
Mailing Address - Street 2:PRECISION OPTICAL DISPENSARY, INC.
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042
Mailing Address - Country:US
Mailing Address - Phone:601-825-1992
Mailing Address - Fax:601-825-1091
Practice Address - Street 1:1490 WEST GOVERNMENT STREET SUITE 8
Practice Address - Street 2:PRECISION OPTICAL DISPENSARY, INC.
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042
Practice Address - Country:US
Practice Address - Phone:601-825-1992
Practice Address - Fax:601-825-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10192156FX1800X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880113Medicaid
MS5361050002Medicare NSC