Provider Demographics
NPI:1386702728
Name:CUSTOM OPTICAL, INC.
Entity type:Organization
Organization Name:CUSTOM OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CORNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-485-2747
Mailing Address - Street 1:1301 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4121
Mailing Address - Country:US
Mailing Address - Phone:601-485-2747
Mailing Address - Fax:601-693-2174
Practice Address - Street 1:1301 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4121
Practice Address - Country:US
Practice Address - Phone:601-485-2747
Practice Address - Fax:601-693-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880086Medicaid
MS00880086Medicaid
MS=========Medicare UPIN