Healthcare Provider Details

I. General information

NPI: 1619038254
Provider Name (Legal Business Name): SAM'S CLUB OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5448 'A' WHITTLESEY BLVD
COLUMBUS GA
31909
US

IV. Provider business mailing address

702 SW 8TH STREET
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 706-649-6377
  • Fax: 706-649-6377
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: MR. MATT MCMULLIN
Title or Position: DIR, CONTRACTING
Credential:
Phone: 479-371-8711