Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 127
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
1450 E GENEVA ST, DELAVAN, WI 53115-2025
(262) 728-0068
Mailing address
1450 E GENEVA ST, DELAVAN, WI 53115-2025
(262) 728-0068
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014127
VIP
—
01
—
17663
MEDICARE
—
05
—
38711100
—
WI
05
—
410985054Y8
—
WI
01
—
42544
DAVIS
—
01
—
CP2230-64
EYEMED
—
Enumeration date
05/19/2006
Last updated
02/11/2008
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