Provider Demographics
NPI:1225088768
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 010
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 1:1150 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4040
Mailing Address - Country:US
Mailing Address - Phone:906-228-4120
Mailing Address - Fax:
Practice Address - Street 1:1150 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4040
Practice Address - Country:US
Practice Address - Phone:906-228-4120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
213121-12OtherEYEMED
014010OtherVIP
MI9000E210890OtherBCBS PIN
0N84900OtherBCBS IL
410985054-4010OtherNVA
42572OtherDAVIS VISION
16749OtherMEDICARECOMPLETE
35465OtherAVESIS
35465OtherAVESIS
1111590051Medicare ID - Type Unspecified
0N84900OtherBCBS IL
0P32290Medicare PIN