Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 004
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
2430 E MASON ST, GREEN BAY, WI 54302-3759
(920) 468-4642
Mailing address
2430 E MASON ST, GREEN BAY, WI 54302-3759
(920) 468-4642
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014004
VIP
—
01
—
17636
MEDICARE
—
05
—
38403100
—
WI
01
—
410985054-4004
NVA
—
01
—
42520
DAVIS
—
Enumeration date
05/19/2006
Last updated
02/11/2008
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