Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 066
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
9520 N NEWPORT HWY, SPOKANE, WA 99218-1219
(509) 466-7136
Mailing address
9520 N NEWPORT HWY, SPOKANE, WA 99218-1219
(509) 466-7136
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014066
VIP
—
01
—
10828
MEDICARE
—
05
—
2005064
—
WA
05
—
2018711
—
WA
01
—
213121-28
EYEMED
—
01
—
35545
AVESIS
—
01
—
42503
DAVIS
—
01
—
G8854723
MEDICARE
—
01
—
WA09210
NORIDIAN SUBMITTER ID
WA
Enumeration date
05/17/2006
Last updated
06/05/2009
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