Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 089
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
1600 W ROSE ST, WALLA WALLA, WA 99362-1771
(509) 525-9301
Mailing address
1600 W ROSE ST, WALLA WALLA, WA 99362-1771
(509) 525-9301
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014089
VIP
—
01
—
17674
MEDICARE
—
05
—
2009942
—
WA
05
—
2130268
—
WA
01
—
213121-1
EYEMED
—
01
—
35551
AVESIS
—
01
—
G8854797
MEDICARE
—
01
—
WA09207
NORIDIAN SUBMITTER ID
WA
Enumeration date
05/17/2006
Last updated
06/05/2009
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