Basic Information
| Provider Information | |||||||||
| NPI: | 1669532040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FISHER FOODS MARKETING INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FISHER OPTICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 FRANK ROAD NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304970205 | ||||||||
| FaxNumber: | 3304971142 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447205664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304331180 | ||||||||
| FaxNumber: | 3303050600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUERR | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTICAL SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3304970205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LDO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 801S | OH | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.