Provider Demographics
NPI:1649215666
Name:SHOPKO STORES, INC.
Entity Type:Organization
Organization Name:SHOPKO STORES, INC.
Other - Org Name:SHOPKO OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
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: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:920-429-4218
Mailing Address - Fax:920-429-5218
Practice Address - Street 1:700 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5263
Practice Address - Country:US
Practice Address - Phone:920-429-4218
Practice Address - Fax:920-429-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier