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NPI Code Detail

MEDICARE: SHOPKO STORES OPERATING CO. LLC

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
1332H00000XEyewear Supplier

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
317645OTHERMEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1410985054-4027OTHERNVA
2146151-1OTHEREYEMED
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
542620OTHERDAVIS
6014027OTHERVIP

General Provider Information

NPI Number : 1750333803
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHOPKO STORES OPERATING CO. LLC
Provider Business Mailing Address
First Line : 4801 WASHINGTON AVE
Second Line :
City : RACINE
State : WI
Zip : 53406-4219
Country : US
Telephone Number : 262-637-3733
Fax Number :
Provider Business Practice Location Address
First Line : 4801 WASHINGTON AVE
Second Line :
City : RACINE
State : WI
Zip : 53406-4219
Country : US
Telephone Number : 262-637-3733
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 : 05/17/2006
Last Update Date : 02/11/2008

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

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