Provider Demographics
NPI:1982656906
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 023
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 1:125 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1807
Mailing Address - Country:US
Mailing Address - Phone:320-587-4945
Mailing Address - Fax:
Practice Address - Street 1:125 MAIN ST N
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-1807
Practice Address - Country:US
Practice Address - Phone:320-587-4945
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
CP2230-20OtherEYEMED
03092036203OtherMN MA PRIMEWEST HEALTH
42609OtherDAVIS
35720OtherMN HEALTH PARTNERS
1C942SHOtherMN MA FIRST PLAN OF MN
1C943SHOtherMN MA FIRST PLAN OF MN
014023OtherVIP
17823OtherMEDICARE
2100134OtherMN MA MEDICA CHOICE CARE
014023OtherVIP
42609OtherDAVIS
MN5695760106Medicare NSC
C04276Medicare PIN