Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 104
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
747 S MAIN ST, BRIGHAM CITY, UT 84302-3359
(435) 723-1800
Mailing address
747 S MAIN ST, BRIGHAM CITY, UT 84302-3359
(435) 723-1800
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014104
VIP
—
01
—
17927
MEDICARE
—
01
—
35524
AVESIS
—
05
—
410985054-165
—
UT
01
—
CP2230-41
EYEMED
—
01
—
UT04883
NORIDIAN SUBMITTER ID
UT
Enumeration date
05/19/2006
Last updated
07/10/2008
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