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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

General Provider Information

NPI Number : 1952356644
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHOPKO STORES OPERATING CO. LLC
Provider Business Mailing Address
First Line : PO BOX 19060
Second Line :
City : GREEN BAY
State : WI
Zip : 54307-9060
Country : US
Telephone Number : 920-429-4218
Fax Number : 920-429-5218
Provider Business Practice Location Address
First Line : 700 PILGRIM WAY
Second Line :
City : GREEN BAY
State : WI
Zip : 54304-5263
Country : US
Telephone Number : 920-429-4218
Fax Number : 920-429-5218
Authorized Official
Title or Position : SR. VICE PRESIDENT HEALTH SERVICES
Name : MR. MICHAEL J BETTIGA
Credential : RPH
Telephone Number : 920-429-4297
Provider Enumeration Date : 05/23/2006
Last Update Date : 10/12/2007

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