Healthcare Provider Details

I. General information

NPI: 1710919816
Provider Name (Legal Business Name): OPTICAL DISPENSARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E UNION ST
NEWARK NY
14513-1503
US

IV. Provider business mailing address

117 E UNION ST
NEWARK NY
14513-1503
US

V. Phone/Fax

Practice location:
  • Phone: 315-331-7917
  • Fax: 315-331-7917
Mailing address:
  • Phone: 315-331-7917
  • Fax: 315-331-7917

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 Number004325
License Number StateNY

VIII. Authorized Official

Name: BRUCE C. MINGER
Title or Position: PRESIDENT
Credential:
Phone: 315-331-7917