Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 130
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
1777 PAULSON RD, RIVER FALLS, WI 54022-8299
(715) 425-6144
Mailing address
1777 PAULSON RD, RIVER FALLS, WI 54022-8299
(715) 425-6144
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000087130
MEDICARE
—
01
—
014130
VIP
—
01
—
17664
MEDICARE
—
05
—
2100691
—
WI
05
—
32682
—
WI
05
—
38449800
—
WI
01
—
410985054-4130
NVA
—
01
—
42550
DAVIS
—
05
—
4C079SH
—
WI
05
—
4C080SH
—
WI
01
—
CP2230-88
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/11/2008
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