Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 128
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
1370 US HIGHWAY 2 E, KALISPELL, MT 59901-3221
(406) 257-1278
Mailing address
1370 US HIGHWAY 2 E, KALISPELL, MT 59901-3221
(406) 257-1278
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000083891
MEDICARE
—
01
—
014128
VIP
—
05
—
0551174
—
MT
01
—
17881
MEDICARE
—
01
—
35493
AVESIS
—
01
—
CP2230-25
EYEMED
—
Enumeration date
05/17/2006
Last updated
04/24/2008
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