Provider Demographics
NPI:1447203146
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 066
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 1:9520 N NEWPORT HWY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1219
Mailing Address - Country:US
Mailing Address - Phone:509-466-7136
Mailing Address - Fax:
Practice Address - Street 1:9520 N NEWPORT HWY
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1219
Practice Address - Country:US
Practice Address - Phone:509-466-7136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
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
G8854723OtherMEDICARE
35545OtherAVESIS
42503OtherDAVIS
WAWA09210OtherNORIDIAN SUBMITTER ID
014066OtherVIP
10828OtherMEDICARE
213121-28OtherEYEMED
WA2005064Medicaid
WA2018711Medicaid
42503OtherDAVIS
WA2018711Medicaid
WA2005064Medicaid
DF1015Medicare PIN