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
2	23361	OTHER		MEDICARE
5	17697	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	014052	OTHER	VIP
3	42599	OTHER	DAVIS
4	35439	OTHER	AVESIS
6	CP2230-8	OTHER	EYEMED

General Provider Information

NPI Number	:	1750334421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO. LLC

Provider Business Mailing Address
First Line	:	615 S MONROE AVE
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50401-5061
Country	:	US
Telephone Number	:	641-424-8271
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 S MONROE AVE
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50401-5061
Country	:	US
Telephone Number	:	641-424-8271
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

Language	Start Address	Practice Location

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