Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 046
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
5646 N 90TH ST, OMAHA, NE 68134-1808
(402) 572-1604
Mailing address
5646 N 90TH ST, OMAHA, NE 68134-1808
(402) 572-1604
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
007120
BLOCK
—
01
—
014046
VIP
—
01
—
17886
MEDICARE
—
01
—
268733
MEDICARE
—
01
—
35505
AVESIS
—
01
—
35862
DAVIS
—
05
—
41098505412
—
NE
01
—
CP2230-32
EYEMED
—
Enumeration date
05/16/2006
Last updated
02/11/2008
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