Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Optical 177
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
2320 LINEVILLE RD, GREEN BAY, WI 54313-8836
(920) 434-5845
Mailing address
2320 LINEVILLE RD, GREEN BAY, WI 54313-8836
(920) 434-5845
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
125950
VIP
—
01
—
146151
EYEMED
—
01
—
1952356644
UNTIED HEALTHCARE
—
05
—
38461000
—
WI
01
—
47608
AVESIS
—
01
—
58936
DAVIS
—
01
—
DF0804
RR MC
—
Enumeration date
12/10/2007
Last updated
04/20/2008
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