Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 057
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
405 COTTONWOOD DR, WINONA, MN 55987-1914
(507) 452-6175
Mailing address
405 COTTONWOOD DR, WINONA, MN 55987-1914
(507) 452-6175
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014057
VIP
—
01
—
17828
MEDICARE
—
01
—
20019120527
MN MA PRIMEWEST HEALTH
—
01
—
213121-18
EYEMED
—
01
—
26679SH
MN MA FIRST PLAN OF MN
—
01
—
34965
MN HEALTH PARTNERS
—
01
—
35482
AVESIS
—
01
—
35584
AVESIS
—
01
—
410985054-4057
NATIONAL VISION ADMIN.
—
01
—
42491
DAVIS
—
01
—
47522SH
MN MA FIRST PLAN OF MN
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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