Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 063
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
4215 YELLOWSTONE AVE, CHUBBUCK, ID 83202-2419
(208) 237-6822
Mailing address
4215 YELLOWSTONE AVE, CHUBBUCK, ID 83202-2419
(208) 237-6822
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000309500
—
ID
01
—
014063
VIP
—
01
—
1593901
MEDICARE
—
01
—
17712
MEDICARE
—
01
—
42499
DAVIS VISION
—
05
—
805180700
—
ID
05
—
806430100
—
ID
01
—
CP2230-10
EYEMED
—
Enumeration date
05/17/2006
Last updated
08/03/2009
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