Provider Demographics
NPI:1962452052
Name:SHOPKO STORES OPERATING COMPANY
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHMONSKY
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:920-468-4642
Mailing Address - Street 1:2430 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3759
Mailing Address - Country:US
Mailing Address - Phone:920-468-4642
Mailing Address - Fax:920-468-3490
Practice Address - Street 1:2430 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3759
Practice Address - Country:US
Practice Address - Phone:920-468-4642
Practice Address - Fax:920-468-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1643-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38403100Medicaid