Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 072
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
2120 THAIN GRADE, LEWISTON, ID 83501-4105
(208) 746-1050
Mailing address
2120 THAIN GRADE, LEWISTON, ID 83501-4105
(208) 746-1050
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000310200
—
ID
01
—
014072
VIP
—
01
—
1379404
MEDICARE
—
01
—
17838
MEDICARE
—
01
—
213121-6
EYEMED
—
01
—
35447
AVESIS
—
05
—
806430106
—
ID
Enumeration date
05/18/2006
Last updated
08/03/2009
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