Provider Demographics
NPI:1124071568
Name:SHOPKO STORES OPERATING CO. LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:500 N HWY 281
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-1821
Mailing Address - Country:US
Mailing Address - Phone:605-225-7677
Mailing Address - Fax:
Practice Address - Street 1:500 N HWY 281
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-1821
Practice Address - Country:US
Practice Address - Phone:605-225-7677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
17911OtherMEDICARE
014049OtherVIP
213121-26OtherEYEMED
35516OtherAVESIS
1111590009Medicare ID - Type Unspecified
014049OtherVIP
DF0754Medicare PIN
SDS101047Medicare PIN