Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 114
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
801 W CENTRAL ENTRANCE, DULUTH, MN 55811-5468
(218) 727-7163
Mailing address
801 W CENTRAL ENTRANCE, DULUTH, MN 55811-5468
(218) 727-7163
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014114
VIP
—
01
—
03092036207
MN MA PRIMEWEST HEALTH
—
01
—
17833
MEDICARE
—
01
—
36060
MN HEALTH PARTNERS
—
01
—
3C266SH
MN BLUE PLUS CARE
—
01
—
3C268SH
MN MA FIRST PLAN OF MN
—
01
—
410985054-4114
NATIONAL VISION ADMIN.
—
01
—
42522
DAVIS
—
01
—
CP2230-18
EYEMED
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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