Provider Demographics
NPI:1164474698
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 038
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
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 1:2208 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-1739
Mailing Address - Country:US
Mailing Address - Phone:308-382-7661
Mailing Address - Fax:
Practice Address - Street 1:2208 N WEBB RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-1739
Practice Address - Country:US
Practice Address - Phone:308-382-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
099548OtherMEDICARE
17882OtherMEDICARE
914651OtherBLOCK
NE10025074000Medicaid
014038OtherVIP
213121-23OtherEYEMED
35496OtherAVESIS
35858OtherDAVIS
NE10025074000Medicaid
014038OtherVIP
213121-23OtherEYEMED
1111590014Medicare ID - Type Unspecified