Provider Demographics
NPI:1144710708
Name:THE SPEC SHOP OPHTHALMIC DISPENSER, PLLC
Entity type:Organization
Organization Name:THE SPEC SHOP OPHTHALMIC DISPENSER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CURRIE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-881-7926
Mailing Address - Street 1:1176 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2102
Mailing Address - Country:US
Mailing Address - Phone:716-881-7926
Mailing Address - Fax:
Practice Address - Street 1:1176 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2102
Practice Address - Country:US
Practice Address - Phone:716-881-7926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY55-009312156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03541260Medicaid