Provider Demographics
NPI:1063465789
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 061
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 1:501 HIGHWAY 10 SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-1250
Mailing Address - Country:US
Mailing Address - Phone:320-253-4695
Mailing Address - Fax:
Practice Address - Street 1:501 HIGHWAY 10 SE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-1250
Practice Address - Country:US
Practice Address - Phone:320-253-4695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
213121-17OtherEYEMED
21527OtherMN HEALTH PARTNERS
410985054-4061OtherNATIONAL VISION ADMIN.
42497OtherDAVIS
20019120524OtherMN MA PRIMEWEST HEALTH
014061OtherVIP
17832OtherMEDICARE
55306HAOtherMN MA FIRST PLAN OF MN
2100301OtherMN MA MEDICA CHOICE CARE
26887SHOtherMN MA FIRST PLAN OF MN
35480OtherAVESIS
410985054-4061OtherNATIONAL VISION ADMIN.
C04276Medicare PIN
42497OtherDAVIS
21527OtherMN HEALTH PARTNERS