Provider Demographics
NPI:1508819137
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 130
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 1:1777 PAULSON RD
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-8299
Mailing Address - Country:US
Mailing Address - Phone:715-425-6144
Mailing Address - Fax:
Practice Address - Street 1:1777 PAULSON RD
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-8299
Practice Address - Country:US
Practice Address - Phone:715-425-6144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
000087130OtherMEDICARE
WI32682Medicaid
410985054-4130OtherNVA
CP2230-88OtherEYEMED
WI2100691Medicaid
WI4C079SHMedicaid
014130OtherVIP
WI38449800Medicaid
42550OtherDAVIS
WI4C080SHMedicaid
17664OtherMEDICARE
WI38449800Medicaid
42550OtherDAVIS
014130OtherVIP
WI2100691Medicaid