Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 052
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
615 S MONROE AVE, MASON CITY, IA 50401-5061
(641) 424-8271
Mailing address
615 S MONROE AVE, MASON CITY, IA 50401-5061
(641) 424-8271
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014052
VIP
—
01
—
17697
MEDICARE
—
01
—
23361
MEDICARE
—
01
—
35439
AVESIS
—
01
—
42599
DAVIS
—
01
—
CP2230-8
EYEMED
—
Enumeration date
05/17/2006
Last updated
02/11/2008
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