Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 058
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
1755 N HUMISTON AVE, WORTHINGTON, MN 56187-1757
(507) 372-7811
Mailing address
1755 N HUMISTON AVE, WORTHINGTON, MN 56187-1757
(507) 372-7811
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014058
VIP
—
01
—
17829
MEDICARE
—
01
—
20019120528
MN MA PRIMEWEST HEALTH
—
01
—
213121-19
EYEMED
—
01
—
33300
MN HEALTH PARTNERS
—
01
—
35487
AVESIS
—
01
—
3C194SH
MN BLUE PLUS CARE
—
01
—
42492
DAVIS
—
Enumeration date
05/17/2006
Last updated
04/15/2008
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