Provider Demographics
NPI:1700838802
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 035
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 1:2820 HIGHWAY 63 S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-5571
Mailing Address - Country:US
Mailing Address - Phone:507-281-0687
Mailing Address - Fax:
Practice Address - Street 1:2820 HIGHWAY 63 S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-5571
Practice Address - Country:US
Practice Address - Phone:507-281-0687
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
17825OtherMEDICARE
20019120523OtherMN MA PRIMEWEST HEALTH
42617OtherDAVIS
213121-15OtherEYEMED
36055OtherMN HEALTH PARTNERS
39687SHOtherMN MA FIRST PLAN OF MN
39701SHOtherMN MA FIRST PLAN OF MN
014035OtherVIP
35471OtherAVESIS
39687SHOtherMN MA FIRST PLAN OF MN
213121-15OtherEYEMED
1111590006Medicare ID - Type Unspecified
MN5695760051Medicare NSC