Provider Demographics
NPI:1790736023
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO OPTICAL 111
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 1:1230 LANCASTER DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-5800
Mailing Address - Country:US
Mailing Address - Phone:503-371-6575
Mailing Address - Fax:
Practice Address - Street 1:1230 LANCASTER DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-5800
Practice Address - Country:US
Practice Address - Phone:503-371-6575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR039904Medicaid
OR039912Medicaid
CP2230-36OtherEYEMED
410985054-4111OtherNVA
35512OtherAVESIS
014111OtherVIP
42514OtherDAVIS VISION
17682Medicare ID - Type UnspecifiedMEDICARECOMPLETE
OR039904Medicaid
35512OtherAVESIS
OR039912Medicaid