Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 065
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
8105 FAIRVIEW AVE, BOISE, ID 83704-8486
(208) 323-9303
Mailing address
8105 FAIRVIEW AVE, BOISE, ID 83704-8486
(208) 323-9303
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000310000
—
ID
01
—
014065
VIP
—
01
—
1379401
MEDICARE
—
01
—
17834
MEDICARE
—
01
—
213121-2
EYEMED
—
01
—
35441
AVESIS
—
01
—
410985054-4065
UWG
—
01
—
42502-000
DAVIS VISION
—
05
—
806430102
—
ID
Enumeration date
05/17/2006
Last updated
08/03/2009
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