Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 053
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
510 E PHILIP AVE, NORTH PLATTE, NE 69101-5538
(308) 534-7271
Mailing address
510 E PHILIP AVE, NORTH PLATTE, NE 69101-5538
(308) 534-7271
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
007127
BLOCK
—
01
—
014053
VIP
—
01
—
096219
MEDICARE
—
01
—
17889
MEDICARE
—
01
—
35502
AVESIS
—
01
—
35865
DAVIS
—
05
—
41098505403
—
NE
01
—
CP2230-29
EYEMED
—
Enumeration date
05/16/2006
Last updated
02/11/2008
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