Provider Demographics
NPI:1942483342
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO OPTICAL 177
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:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:2320 LINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8836
Mailing Address - Country:US
Mailing Address - Phone:920-434-5845
Mailing Address - Fax:
Practice Address - Street 1:2320 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-8836
Practice Address - Country:US
Practice Address - Phone:920-434-5845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
47608OtherAVESIS
1952356644OtherUNTIED HEALTHCARE
WI38461000Medicaid
146151OtherEYEMED
1952356644OtherNETWORK HEALTH
125950OtherVIP
58936OtherDAVIS
DF0804OtherRR MC
DF0804OtherRR MC
5695760139Medicare NSC