Provider Demographics
NPI:1295788818
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 1:801 W CENTRAL ENTRANCE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5468
Mailing Address - Country:US
Mailing Address - Phone:218-727-7163
Mailing Address - Fax:
Practice Address - Street 1:801 W CENTRAL ENTRANCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5468
Practice Address - Country:US
Practice Address - Phone:218-727-7163
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
410985054-4114OtherNATIONAL VISION ADMIN.
36060OtherMN HEALTH PARTNERS
014114OtherVIP
17833OtherMEDICARE
3C268SHOtherMN MA FIRST PLAN OF MN
42522OtherDAVIS
CP2230-18OtherEYEMED
3C266SHOtherMN BLUE PLUS CARE
03092036207OtherMN MA PRIMEWEST HEALTH
DF0849Medicare PIN
3C266SHOtherMN BLUE PLUS CARE
03092036207OtherMN MA PRIMEWEST HEALTH
0154160161Medicare ID - Type Unspecified