Provider Demographics
NPI:1396797486
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 1:2530 RUDKIN RD
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1632
Mailing Address - Country:US
Mailing Address - Phone:509-248-9833
Mailing Address - Fax:
Practice Address - Street 1:2530 RUDKIN RD
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1632
Practice Address - Country:US
Practice Address - Phone:509-248-9833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8854795OtherMEDICARE
35549OtherAVESIS
WAWA09209OtherNORIDIAN SUBMITTER ID
17672OtherMEDICARE
WA2029924Medicaid
014073OtherVIP
213121-30OtherEYEMED
WA2200004Medicaid
WA2029924Medicaid
WA2200004Medicaid
DF1015Medicare PIN
1111590012Medicare ID - Type Unspecified