Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 005
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
230 N WISCONSIN ST, DE PERE, WI 54115-2735
(920) 336-3390
Mailing address
230 N WISCONSIN ST, DE PERE, WI 54115-2735
(920) 336-3390
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014005
VIP
—
01
—
17637
MEDICARE
—
05
—
38428900
—
WI
01
—
410985054-4005
NVA
—
01
—
42523
DAVIS
—
01
—
CP2230-70
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/11/2008
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