Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 011
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
500 S CARPENTER AVE, KINGSFORD, MI 49802-4529
(906) 779-9164
Mailing address
500 S CARPENTER AVE, KINGSFORD, MI 49802-4529
(906) 779-9164
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014011
VIP
—
01
—
0P06320
MEDICARE
—
01
—
17841
MEDICARECOMPLETE
—
01
—
213121-11
EYEMED
—
01
—
35464
AVESIS
—
05
—
38443600
—
WI
01
—
410985054-4011
NVA
—
01
—
42578
DAVIS
—
Enumeration date
05/12/2006
Last updated
02/11/2008
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