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	License Number	License Number State
1	332H00000X	Eyewear Supplier

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	I8499	OTHER		MEDICARE
5	17709	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
2	014142	OTHER	VIP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	CP2521-2	OTHER	EYEMED

General Provider Information

NPI Number	:	1629021480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO. LLC

Provider Business Mailing Address
First Line	:	4810 AVENUE O
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-9677
Country	:	US
Telephone Number	:	319-372-8633
Fax Number	:

Provider Business Practice Location Address
First Line	:	4810 AVENUE O
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-9677
Country	:	US
Telephone Number	:	319-372-8633
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	:	01/30/2008

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