| Organization Name: | TRISTATE OPTICAL, INC. |
| NPI Number: | 1013903962 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JERRY L BRADLEY (VICE PRESIDENT) |
| Mailing Address: | 6424 W Jefferson Blvd Fort Wayne |
| State: | IN US |
| Postal Code: | 468046204 |
| Phone Number: | 2604362020 |
| Fax Number: | 2604367628 |
| NPI Enumeration Date: | 09/26/2005 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332H00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Eyewear Supplier (Equipment, not the service) |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An organization that provides spectacles, contact lenses, and other vision enhancement devices prescribed by an optometrist or ophthalmologist. |