Provider Demographics
NPI:1457304024
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 059
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 1:1001 HIGHWAY 15 S
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4456
Mailing Address - Country:US
Mailing Address - Phone:507-238-9490
Mailing Address - Fax:
Practice Address - Street 1:1001 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4456
Practice Address - Country:US
Practice Address - Phone:507-238-9490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
35469OtherAVESIS
CP2230-19OtherEYEMED
03092036205OtherMN MA PRIMEWEST HEALTH
36058OtherMN HEALTH PARTNERS
42493OtherDAVIS
014059OtherVIP
17830OtherMEDICARE
3C159SHOtherMN MA FIRST PLAN OF MN
3C391SHOtherMN MA FIRST PLAN OF MN
C04276Medicare PIN
42493OtherDAVIS
36058OtherMN HEALTH PARTNERS
17830OtherMEDICARE