Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 073
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
2530 RUDKIN RD, UNION GAP, WA 98903-1632
(509) 248-9833
Mailing address
2530 RUDKIN RD, UNION GAP, WA 98903-1632
(509) 248-9833
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014073
VIP
—
01
—
17672
MEDICARE
—
05
—
2029924
—
WA
01
—
213121-30
EYEMED
—
05
—
2200004
—
WA
01
—
35549
AVESIS
—
01
—
G8854795
MEDICARE
—
01
—
WA09209
NORIDIAN SUBMITTER ID
WA
Enumeration date
05/17/2006
Last updated
06/05/2009
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