Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 016
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
2530 1ST AVE N, ESCANABA, MI 49829-1390
(906) 786-2295
Mailing address
2530 1ST AVE N, ESCANABA, MI 49829-1390
(906) 786-2295
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014016
VIP
—
01
—
0P06330
MEDICARE
—
01
—
17875
MEDICARE
—
01
—
213121-9
EYEMED
—
01
—
35462
AVESIS
—
01
—
411740865-4016
NVA
—
01
—
42600
DAVIS
—
Enumeration date
05/16/2006
Last updated
02/11/2008
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