Provider Demographics
NPI:1598321986
Name:SHOPTIKAL LLC
Entity Type:Organization
Organization Name:SHOPTIKAL LLC
Other - Org Name:SHOPKO OPTICAL 4125
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRIESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-606-6804
Mailing Address - Street 1:PO BOX 19060
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1524 S WEST AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6702
Practice Address - Country:US
Practice Address - Phone:815-232-3057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-12
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier