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Organization
SHOPKO STORES OPERATING CO. LLC
Active
Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 061
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
501 HIGHWAY 10 SE, SAINT CLOUD, MN 56304-1250
(320) 253-4695
Mailing address
501 HIGHWAY 10 SE, SAINT CLOUD, MN 56304-1250
(320) 253-4695
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014061
VIP
—
01
—
17832
MEDICARE
—
01
—
20019120524
MN MA PRIMEWEST HEALTH
—
01
—
2100301
MN MA MEDICA CHOICE CARE
—
01
—
213121-17
EYEMED
—
01
—
21527
MN HEALTH PARTNERS
—
01
—
26887SH
MN MA FIRST PLAN OF MN
—
01
—
35480
AVESIS
—
01
—
410985054-4061
NATIONAL VISION ADMIN.
—
01
—
42497
DAVIS
—
01
—
55306HA
MN MA FIRST PLAN OF MN
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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