MEDICARE: SAM'S CLUB OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1124123914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAM'S CLUB OPTICAL

Provider Business Mailing Address
First Line	:	1 CUSTOMER DR
Second Line	:	MS 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1946 10TH AVENUE NORTH
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5624
Country	:	US
Telephone Number	:	843-946-9521
Fax Number	:	843-916-1481

Authorized Official
Title or Position	:	SR. DIRECTOR
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	479-371-1168

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	10/14/2025

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Directions to “SAM'S CLUB OPTICAL ” Practice Location

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