Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 171
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
1800 PLOVER RD, PLOVER, WI 54467-3978
(715) 342-9634
Mailing address
1800 PLOVER RD, PLOVER, WI 54467-3978
(715) 342-9634
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014171
VIP
—
01
—
17666
MEDICARE
—
01
—
35583
AVESIS
—
05
—
38716300
—
WI
01
—
42570
DAVIS
—
01
—
47565
MEDICARE
—
01
—
CP2230-86
EYEMED
—
Enumeration date
05/18/2006
Last updated
02/11/2008
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