Provider Demographics
NPI:1770761462
Name:THE OPTICAL SHOP
Entity type:Organization
Organization Name:THE OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:LAGRONE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:912-354-6445
Mailing Address - Street 1:712 E 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4716
Mailing Address - Country:US
Mailing Address - Phone:912-354-6445
Mailing Address - Fax:912-354-3393
Practice Address - Street 1:712 E 69TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4716
Practice Address - Country:US
Practice Address - Phone:912-354-6445
Practice Address - Fax:912-354-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4106600001Medicare NSC