Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 031
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
5300 52ND ST, KENOSHA, WI 53144-2310
(262) 658-8119
Mailing address
5300 52ND ST, KENOSHA, WI 53144-2310
(262) 658-8119
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014031
VIP
—
01
—
17649
MEDICARE
—
05
—
38413700
—
WI
01
—
410985054-4031
NVA
—
01
—
42611
DAVIS
—
01
—
CP2230-73
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/11/2008
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