Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 069
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
217 W IRONWOOD DR, COEUR D ALENE, ID 83814-2651
(208) 765-8078
Mailing address
217 W IRONWOOD DR, COEUR D ALENE, ID 83814-2651
(208) 765-8078
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000309800
—
ID
01
—
014069
VIP
—
01
—
1379403
MEDICARE
—
01
—
17837
MEDICARE
—
01
—
213121-4
EYEMED
—
01
—
35444
AVESIS
—
01
—
42507
DAVIS VISION
—
05
—
806430105
—
ID
Enumeration date
05/18/2006
Last updated
08/03/2009
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