Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 010
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
1150 W WASHINGTON ST, MARQUETTE, MI 49855-4040
(906) 228-4120
Mailing address
1150 W WASHINGTON ST, MARQUETTE, MI 49855-4040
(906) 228-4120
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014010
VIP
—
01
—
0N84900
BCBS IL
—
01
—
16749
MEDICARECOMPLETE
—
01
—
213121-12
EYEMED
—
01
—
35465
AVESIS
—
01
—
410985054-4010
NVA
—
01
—
42572
DAVIS VISION
—
01
—
9000E210890
BCBS PIN
MI
Enumeration date
05/12/2006
Last updated
05/29/2008
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