Healthcare Provider Details

I. General information

NPI: 1295040665
Provider Name (Legal Business Name): SAM'S CLUB OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 BRYANT DRIVE
NICHOLASVILLE KY
40356-9225
US

IV. Provider business mailing address

1 CUSTOMER DR MS 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 859-881-0695
  • Fax: 859-881-0698
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SR DIRECTOR
Credential:
Phone: 480-853-0515