Provider Demographics
NPI:1033161419
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 113
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:5500 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6326
Mailing Address - Country:US
Mailing Address - Phone:360-456-4532
Mailing Address - Fax:
Practice Address - Street 1:5500 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6326
Practice Address - Country:US
Practice Address - Phone:360-456-4532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17676OtherMEDICARE
CP2230-57OtherEYEMED
WA2020667Medicaid
WAWA09205OtherNORIDIAN SUBMITTER ID
014113OtherVIP
G8855125OtherMEDICARE
WA2016293Medicaid
0154160170Medicare ID - Type Unspecified
DF1015Medicare PIN
17676OtherMEDICARE
CP2230-57OtherEYEMED