Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Optical 111
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
1230 LANCASTER DR SE, SALEM, OR 97317-5800
(503) 371-6575
Mailing address
1230 LANCASTER DR SE, SALEM, OR 97317-5800
(503) 371-6575
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014111
VIP
—
05
—
039904
—
OR
05
—
039912
—
OR
01
—
35512
AVESIS
—
01
—
410985054-4111
NVA
—
01
—
42514
DAVIS VISION
—
01
—
CP2230-36
EYEMED
—
Enumeration date
05/12/2006
Last updated
11/20/2008
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