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Organization
SHOPKO STORES OPERATING CO. LLC
Active
Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 4017
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
4161 2ND ST S, SAINT CLOUD, MN 56301-3761
(320) 253-5994
Mailing address
4161 2ND ST S, SAINT CLOUD, MN 56301-3761
(320) 253-5994
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014017
VIP
—
01
—
03092036202
MN MA PRIMEWEST HEALTH
—
01
—
17821
MEDICARE
—
01
—
2123169
MN MA MEDICA CHOICE CARE
—
01
—
23667
MN HEALTH PARTNERS
—
01
—
35479
AVESIS
—
01
—
35585
AVESIS
—
01
—
410985054-4017
NATIONAL VISION ADMIN.
—
01
—
42601
DAVIS
—
01
—
77166SH
MN MA FIRST PLAN OF MN
—
01
—
77168MA
MN BLUE PLUS CARE
—
01
—
CP2230-22
EYEMED
—
Enumeration date
05/16/2006
Last updated
04/15/2008
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