Provider Demographics
NPI:1336191501
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 1:510 E PHILIP AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5538
Mailing Address - Country:US
Mailing Address - Phone:308-534-7271
Mailing Address - Fax:
Practice Address - Street 1:510 E PHILIP AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5538
Practice Address - Country:US
Practice Address - Phone:308-534-7271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
014053OtherVIP
35502OtherAVESIS
35865OtherDAVIS
CP2230-29OtherEYEMED
096219OtherMEDICARE
NE41098505403Medicaid
007127OtherBLOCK
17889OtherMEDICARE
17889OtherMEDICARE
NE5695760062Medicare NSC
NE099830Medicare PIN
014053OtherVIP