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Organization
SHOPKO STORES OPERATING CO. LLC
Active
Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 021
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
1850 E MADISON AVE, MANKATO, MN 56001-5448
(507) 387-6517
Mailing address
1850 E MADISON AVE, MANKATO, MN 56001-5448
(507) 387-6517
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014021
VIP
—
01
—
17822
MEDICARE
—
01
—
20019120525
MN MA PRIMEWEST HEALTH
—
01
—
2100546
MN MA MEDICA CHOICE CARE
—
01
—
213121-14
EYEMED
—
01
—
35694
AVESIS
—
01
—
410985054-4021
NATIONAL VISION ADMIN.
—
01
—
41619SH
MN MA FIRST PLAN OF MN
—
01
—
42607
DAVIS
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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