Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 062
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
301 NORTHWEST BYP, GREAT FALLS, MT 59404-4125
(406) 727-9724
Mailing address
301 NORTHWEST BYP, GREAT FALLS, MT 59404-4125
(406) 727-9724
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0550576
—
MT
01
—
17877
MEDICARE
—
01
—
213121-20
EYEMED
—
01
—
35491
AVESIS
—
Enumeration date
05/18/2006
Last updated
04/24/2008
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