Provider Demographics
NPI:1558313783
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 045
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 1:601 GALVIN RD S
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-2249
Mailing Address - Country:US
Mailing Address - Phone:402-293-1840
Mailing Address - Fax:
Practice Address - Street 1:601 GALVIN RD S
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-2249
Practice Address - Country:US
Practice Address - Phone:402-293-1840
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
014045OtherVIP
17885OtherMEDICARE
35495OtherAVESIS
213121-22OtherEYEMED
003340OtherBLOCK
NE10025073800Medicaid
35861OtherDAVIS
1111590010Medicare ID - Type Unspecified
NE5695760117Medicare NSC
014045OtherVIP
35495OtherAVESIS