MEDICARE: SHOPKO STORES OPERATING CO. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	156FX1800X	Optician
3	332H00000X	Eyewear Supplier

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	17932	OTHER		MEDICARE
6	000090125	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	014109	OTHER		VIP
3	UT04871	OTHER	UT	NORIDIAN SUBMITTER ID
4	42510	OTHER		DAVIS
7	CP2230-48	OTHER		EYEMED

General Provider Information

NPI Number	:	1295788065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO. LLC

Provider Business Mailing Address
First Line	:	4060 RIVERDALE RD
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	801-392-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4060 RIVERDALE RD
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	801-392-4300
Fax Number	:

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/10/2008

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Directions to “SHOPKO STORES OPERATING CO. LLC ” Practice Location

Language	Start Address	Practice Location

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