Provider Demographics
NPI:1124070644
Name:SHOPKO STORES OPERATING CO. LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:14445 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5401
Mailing Address - Country:US
Mailing Address - Phone:402-333-7462
Mailing Address - Fax:
Practice Address - Street 1:14445 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5401
Practice Address - Country:US
Practice Address - Phone:402-333-7462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE41098505420Medicaid
CP2230-30OtherEYEMED
17890OtherMEDICARE
014056OtherVIP
35503OtherAVESIS
35866OtherDAVIS
009774OtherBLOCK
092603OtherMEDICARE
DF0848Medicare PIN
092603OtherMEDICARE
35866OtherDAVIS
NE5695760008Medicare NSC