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	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1720231228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAM'S CLUB OPTICAL

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0235
Country	:	US
Telephone Number	:	479-204-8320
Fax Number	:	479-277-8176

Provider Business Practice Location Address
First Line	:	5565 20TH ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4632
Country	:	US
Telephone Number	:	772-978-0722
Fax Number	:

Authorized Official
Title or Position	:	NPI ASSOCIATE
Name	:	HOLLY C WILKINSON
Credential	:
Telephone Number	:	479-204-8320

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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Directions to “SAM'S CLUB OPTICAL ” Practice Location

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