Provider Demographics
NPI:1285957985
Name:THE OPTICAL SHOP
Entity type:Organization
Organization Name:THE OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:843-655-2299
Mailing Address - Street 1:3911A, HWY 17 BYPASS
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:843-651-8214
Mailing Address - Fax:
Practice Address - Street 1:4335 DICK POND RD # 419
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6809
Practice Address - Country:US
Practice Address - Phone:843-347-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC436156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty