Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 076
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
1601 W 41ST ST, SIOUX FALLS, SD 57105-6371
(605) 338-3225
Mailing address
1601 W 41ST ST, SIOUX FALLS, SD 57105-6371
(605) 338-3225
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014076
VIP
—
01
—
17913
MEDICARE
—
01
—
35520
AVESIS
—
01
—
4997995
WELLMARK
—
01
—
CP2230-38
EYEMED
—
Enumeration date
05/19/2006
Last updated
08/28/2008
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