Healthcare Provider Details

I. General information

NPI: 1689835647
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5630 ST CROIX TRAIL
NORTH BRANCH MN
55056
US

IV. Provider business mailing address

5630 ST CROIX TRAIL
NORTH BRANCH MN
55056
US

V. Phone/Fax

Practice location:
  • Phone: 651-674-9951
  • Fax: 651-674-9907
Mailing address:
  • Phone: 651-674-9951
  • Fax: 651-674-9907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

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