Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 007
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
4344 MORMON COULEE RD, LA CROSSE, WI 54601-7908
(608) 788-8800
Mailing address
4344 MORMON COULEE RD, LA CROSSE, WI 54601-7908
(608) 788-8800
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000087829
MEDICARE
—
01
—
014007
VIP
—
01
—
17638
MEDICARE
—
01
—
35570
AVESIS
—
05
—
38423700
—
WI
01
—
42527
DAVIS
—
01
—
CP2230-75
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/08/2008
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