Healthcare Provider Details

I. General information

NPI: 1790736023
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 LANCASTER DR SE
SALEM OR
97317-5800
US

IV. Provider business mailing address

1230 LANCASTER DR SE
SALEM OR
97317-5800
US

V. Phone/Fax

Practice location:
  • Phone: 503-371-6575
  • Fax:
Mailing address:
  • Phone: 503-371-6575
  • Fax:

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