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Organization
SHOPKO STORES OPERATING CO LLC
Active
Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Optical 093
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
60 NE BEND RIVER MALL DR, BEND, OR 97701-7528
(541) 385-6079
Mailing address
60 NE BEND RIVER MALL DR, BEND, OR 97701-7528
(541) 385-6079
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005251
—
OR
01
—
014093
VIP
—
05
—
022688
—
OR
01
—
112254
OR MEDICARE-NORIDIAN
—
01
—
17679
MEDICARECOMPLETE
—
01
—
35508
AVESIS
—
01
—
42573
DAVIS VISION
—
01
—
CP2230-33
EYEMED
—
Enumeration date
05/12/2006
Last updated
03/19/2008
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