Provider Demographics
NPI:1396993622
Name:PJ OPTICAL
Entity type:Organization
Organization Name:PJ OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROXBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-612-2706
Mailing Address - Street 1:1010 ROUTE 112
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3387
Mailing Address - Country:US
Mailing Address - Phone:631-476-3500
Mailing Address - Fax:
Practice Address - Street 1:1010 ROUTE 112
Practice Address - Street 2:SUITE 300
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3387
Practice Address - Country:US
Practice Address - Phone:631-476-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6144990001Medicare NSC