Healthcare Provider Details

I. General information

NPI: 1578584686
Provider Name (Legal Business Name): COLUMBUS OPTICAL DISPENSARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 5TH ST N
COLUMBUS MS
39705
US

IV. Provider business mailing address

1928 5TH ST N
COLUMBUS MS
39705-2206
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-5781
  • Fax: 662-328-7281
Mailing address:
  • Phone: 662-328-5781
  • Fax: 662-328-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAROD LEE
Title or Position: OWNER
Credential:
Phone: 662-328-5781