Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 173
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
105 N MAIN ST, EAST PEORIA, IL 61611-2543
(309) 694-6470
Mailing address
105 N MAIN ST, EAST PEORIA, IL 61611-2543
(309) 694-6470
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014173
VIP
—
01
—
17690
MEDICARE
—
01
—
42574
DAVIS
—
01
—
CP2230-14
EYEMED
—
Enumeration date
05/16/2006
Last updated
09/28/2007
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