Healthcare Provider Details

I. General information

NPI: 1912219338
Provider Name (Legal Business Name): SAM'S CLUB OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 BOBBY JONES EXPY
AUGUSTA GA
30907-2433
US

IV. Provider business mailing address

702 SW 8TH STREET
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-7846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: HOLLY C WILKINSON
Title or Position: COMMERCIAL CONTRACTING SPECIALIST
Credential:
Phone: 479-204-8320