Provider Demographics
NPI:1154776672
Name:TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE
Entity type:Organization
Organization Name:TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUPPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-804-3412
Mailing Address - Street 1:6260 31ST TER N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-2402
Mailing Address - Country:US
Mailing Address - Phone:727-804-3412
Mailing Address - Fax:727-345-5502
Practice Address - Street 1:180 RACE TRACK RD N UNIT 32
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3211
Practice Address - Country:US
Practice Address - Phone:727-804-3412
Practice Address - Fax:813-855-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier