Provider Demographics
NPI:1851341390
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 011
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 1:500 S CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4529
Mailing Address - Country:US
Mailing Address - Phone:906-779-9164
Mailing Address - Fax:
Practice Address - Street 1:500 S CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4529
Practice Address - Country:US
Practice Address - Phone:906-779-9164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
014011OtherVIP
213121-11OtherEYEMED
WI38443600Medicaid
410985054-4011OtherNVA
0P06320OtherMEDICARE
35464OtherAVESIS
42578OtherDAVIS
17841OtherMEDICARECOMPLETE
410985054-4011OtherNVA
35464OtherAVESIS
DF0754Medicare PIN
MI5695760124Medicare NSC