Healthcare Provider Details

I. General information

NPI: 1609828136
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 N MAIN ST
LOGAN UT
84341-2221
US

IV. Provider business mailing address

1341 N MAIN ST
LOGAN UT
84341-2221
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-0700
  • Fax:
Mailing address:
  • Phone: 435-753-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier35721
Identifier TypeOTHER
Identifier State
Identifier IssuerAVESIS
# 2
Identifier014091
Identifier TypeOTHER
Identifier State
Identifier IssuerVIP
# 3
Identifier410985054-148
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 4
IdentifierCP2230-43
Identifier TypeOTHER
Identifier State
Identifier IssuerEYEMED
# 5
Identifier17924
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE
# 6
IdentifierUT04878
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerNORIDIAN SUBMITTER ID
# 7
Identifier42567
Identifier TypeOTHER
Identifier State
Identifier IssuerDAVIS

VIII. Authorized Official

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