Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 142
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
4810 AVENUE O, FORT MADISON, IA 52627-9677
(319) 372-8633
Mailing address
4810 AVENUE O, FORT MADISON, IA 52627-9677
(319) 372-8633
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014142
VIP
—
05
—
0252080
—
IA
01
—
17709
MEDICARE
—
01
—
CP2521-2
EYEMED
—
01
—
I8499
MEDICARE
—
Enumeration date
05/19/2006
Last updated
01/30/2008
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