Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 025
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
1200 SUSAN DR, MARSHALL, MN 56258-2580
(507) 537-9652
Mailing address
1200 SUSAN DR, MARSHALL, MN 56258-2580
(507) 537-9652
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014025
VIP
—
01
—
03092036204
MN MA PRIMEWEST HEALTH
—
01
—
17824
MEDICARE
—
01
—
35695
AVESIS
—
01
—
3C214SH
MN MA FIRST PLAN OF MN
—
01
—
42615
DAVIS
—
01
—
4C071SH
MN BLUE PLUS CARE
—
01
—
CP2230-21
EYEMED
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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