Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 164
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
255 JOHN F KENNEDY RD, DUBUQUE, IA 52002-5313
(563) 583-5895
Mailing address
255 JOHN F KENNEDY RD, DUBUQUE, IA 52002-5313
(563) 583-5895
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014164
VIP
—
05
—
025-6347
—
IA
01
—
17711
MEDICARE
—
01
—
35437
AVESIS
—
01
—
70091
MEDICARE
—
01
—
OP1541
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/11/2008
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