Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 070
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
13414 E SPRAGUE AVE, SPOKANE VALLEY, WA 99216-0848
(509) 924-2015
Mailing address
13414 E SPRAGUE AVE, SPOKANE VALLEY, WA 99216-0848
(509) 924-2015
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014070
VIP
—
01
—
10829
MEDICARE
—
05
—
2005056
—
WA
05
—
2013142
—
WA
01
—
213121-29
EYEMED
—
01
—
35546
AVESIS
—
01
—
G8854794
MEDICARE
—
01
—
WA09206
NORIDIAN SUBMITTER ID
WA
Enumeration date
05/17/2006
Last updated
06/05/2009
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