Provider Demographics
NPI:1558314104
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 041
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 1:1209 18TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-1881
Mailing Address - Country:US
Mailing Address - Phone:507-437-8228
Mailing Address - Fax:
Practice Address - Street 1:1209 18TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-1881
Practice Address - Country:US
Practice Address - Phone:507-437-8228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
32500SHOtherMN BLUE PLUS CARE
36057OtherMN HEALTH PARTNERS
014041OtherVIP
20019120526OtherMN MA PRIMEWEST HEALTH
42593OtherDAVIS
32437SHOtherMN MA FIRST PLAN OF MN
17827OtherMEDICARE
213121-13OtherEYEMED
35554OtherAVESIS
DF0849Medicare PIN
36057OtherMN HEALTH PARTNERS
32437SHOtherMN MA FIRST PLAN OF MN
MN5695760050Medicare NSC