Provider Demographics
NPI:1174575500
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 1:4161 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3761
Mailing Address - Country:US
Mailing Address - Phone:320-253-5994
Mailing Address - Fax:
Practice Address - Street 1:4161 2ND ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3761
Practice Address - Country:US
Practice Address - Phone:320-253-5994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
42601OtherDAVIS
014017OtherVIP
77166SHOtherMN MA FIRST PLAN OF MN
17821OtherMEDICARE
2123169OtherMN MA MEDICA CHOICE CARE
23667OtherMN HEALTH PARTNERS
CP2230-22OtherEYEMED
35585OtherAVESIS
77168MAOtherMN BLUE PLUS CARE
03092036202OtherMN MA PRIMEWEST HEALTH
35479OtherAVESIS
410985054-4017OtherNATIONAL VISION ADMIN.
03092036202OtherMN MA PRIMEWEST HEALTH
77168MAOtherMN BLUE PLUS CARE
35585OtherAVESIS
MN5695760020Medicare NSC