Provider Demographics
NPI:1871545996
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 1:1755 N HUMISTON AVE
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1757
Mailing Address - Country:US
Mailing Address - Phone:507-372-7811
Mailing Address - Fax:
Practice Address - Street 1:1755 N HUMISTON AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1757
Practice Address - Country:US
Practice Address - Phone:507-372-7811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
17829OtherMEDICARE
3C194SHOtherMN BLUE PLUS CARE
20019120528OtherMN MA PRIMEWEST HEALTH
42492OtherDAVIS
213121-19OtherEYEMED
35487OtherAVESIS
014058OtherVIP
33300OtherMN HEALTH PARTNERS
35487OtherAVESIS
C04276Medicare PIN
33300OtherMN HEALTH PARTNERS
213121-19OtherEYEMED