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General NPI Number Information
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NPI Number | 1952642589
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Entity Type | Organization
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Legal Business Name | SHOPKO STORES OPERATING CO.,LLC
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Dates
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Enumeration Date | 03/06/2013
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Last Update Date | 03/06/2013
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Provider Practice Location Address
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Address Line | 825 W FULTON ST
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City | WAUPACA
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State | WI
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Zip | 54981-1471
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Country | US
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Telephone | 715-258-9000
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Fax | 715-258-4119
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Provider Business Mailing Address
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Address Line | 825 W FULTON ST
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City | WAUPACA
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State | WI
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Zip | 54981-1471
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Country | US
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Telephone | 715-258-9000
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Fax | 715-258-4119
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT AND COO
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Name | MICHAEL BETTIGA
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Credential | RPH
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Telephone | 92042949297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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