Healthcare Provider Details

I. General information

NPI: 1902920093
Provider Name (Legal Business Name): SAM'S CLUB OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NORTH MAIN ST
ROSWELL NM
88201
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-6209
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-9852
  • Fax:
Mailing address:
  • Phone: 479-277-1703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MRS. NORMA B SMITH
Title or Position: MPI ASSOCIATE
Credential:
Phone: 479-277-1703