MEDICARE: SHOPKO STORES OPERATING CO. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	156FX1800X	Optician
3	332H00000X	Eyewear Supplier

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17677	OTHER		MEDICARE
3	G8855121	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	014122	OTHER		VIP
4	35552	OTHER		AVESIS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	WA09230	OTHER	WA	NORIDIAN SUBMITTER ID
7	CP2230-60	OTHER		EYEMED

General Provider Information

NPI Number	:	1386696383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO. LLC

Provider Business Mailing Address
First Line	:	1340 N WENATCHEE AVE
Second Line	:
City	:	WENATCHEE
State	:	WA
Zip	:	98801-1558
Country	:	US
Telephone Number	:	509-663-8868
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 N WENATCHEE AVE
Second Line	:
City	:	WENATCHEE
State	:	WA
Zip	:	98801-1558
Country	:	US
Telephone Number	:	509-663-8868
Fax Number	:

Authorized Official
Title or Position	:	SR. VICE PRESIDENT HEALTH SERVICES
Name	:	MICHAEL J BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	06/05/2009

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Directions to “SHOPKO STORES OPERATING CO. LLC ” Practice Location

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