Provider Demographics
NPI:1932152501
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 028
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 1:800 E MAES AVE
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-1527
Mailing Address - Country:US
Mailing Address - Phone:920-788-4114
Mailing Address - Fax:
Practice Address - Street 1:800 E MAES AVE
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-1527
Practice Address - Country:US
Practice Address - Phone:920-788-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
17646OtherMEDICARE
42621OtherDAVIS
014028OtherVIP
35569OtherAVESIS
WI38409100Medicaid
CP2230-74OtherEYEMED
410985054-4028OtherNVA
35569OtherAVESIS
17646OtherMEDICARE
42621OtherDAVIS