Provider Demographics
NPI:1770748287
Name:COLQUITT OPTICAL HOUSE
Entity type:Organization
Organization Name:COLQUITT OPTICAL HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED DISPENSING OPTICIAN/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:STRICKLAND
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:229-891-0525
Mailing Address - Street 1:22 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-4750
Mailing Address - Country:US
Mailing Address - Phone:229-890-2466
Mailing Address - Fax:
Practice Address - Street 1:22 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-4750
Practice Address - Country:US
Practice Address - Phone:229-890-2466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA805332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier