Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 075
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
2510 S RESERVE ST, MISSOULA, MT 59801-7546
(406) 721-4646
Mailing address
2510 S RESERVE ST, MISSOULA, MT 59801-7546
(406) 721-4646
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014075
VIP
—
05
—
0550862
—
MT
01
—
17878
MEDICARE
—
01
—
213121-21
EYEMED
—
01
—
35494
AVESIS
—
Enumeration date
05/18/2006
Last updated
04/24/2008
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