Healthcare Provider Details

I. General information

NPI: 1164475752
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CALDWELL BLVD
NAMPA ID
83651-1510
US

IV. Provider business mailing address

2100 CALDWELL BLVD
NAMPA ID
83651-1510
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-6895
  • Fax:
Mailing address:
  • Phone: 208-466-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateNULL

VIII. Authorized Official

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