Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 174
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
2323 W PIONEER PKWY, PEORIA, IL 61615-1833
(309) 691-4815
Mailing address
2323 W PIONEER PKWY, PEORIA, IL 61615-1833
(309) 691-4815
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014174
VIP
—
01
—
17691
MEDICARE
—
01
—
35458
AVESIS
—
01
—
42575
DAVIS
—
01
—
CP230-16
EYEMED
—
Enumeration date
05/17/2006
Last updated
09/28/2007
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