| Organization Name: | SAM'S CLUB OPTICAL |
| NPI Number: | 1053495044 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TAMMY J BOYD (CONTRACT COORDINATOR) |
| Mailing Address: | 5725 E. Franklin Rd Nampa |
| State: | ID US |
| Postal Code: | 83687 |
| Phone Number: | 2084429863 |
| Fax Number: | |
| NPI Enumeration Date: | 10/25/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |