Provider Demographics
NPI:1841362134
Name:SHAFFER'S OPTICAL EXPRESS
Entity type:Organization
Organization Name:SHAFFER'S OPTICAL EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:JR. VICE PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-425-9099
Mailing Address - Street 1:5205 HIGHWAY 11 N
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-5001
Mailing Address - Country:US
Mailing Address - Phone:601-425-9099
Mailing Address - Fax:601-425-9018
Practice Address - Street 1:5205 HIGHWAY 11 N
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-5001
Practice Address - Country:US
Practice Address - Phone:601-425-9099
Practice Address - Fax:601-425-9018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880183Medicaid