NPIMap

Organization Active NPI

Shopko Stores Operating Co. LLC

Doing business as ShopKo Optical 174

  • Eyewear Supplier
  • Peoria, IL
National Provider Identifier
1073565180
Registry record updated Sep 28, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
SHOPKO STORES OPERATING CO. LLC
Doing business as
ShopKo Optical 174
Practice address
2323 W Pioneer Pkwy
Peoria, IL 61615-1833
Phone
(309) 691-4815
NPI assigned
May 17, 2006
Last updated
Sep 28, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 28, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael J Bettiga, RPH
Title
Sr. Vice President Health Services
Phone
(920) 429-4297

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X NU Primary

Addresses

Primary practice location

2323 W Pioneer Pkwy
Peoria, IL 61615-1833

Mailing address

2323 W Pioneer Pkwy
Peoria, IL 61615-1833
Phone (309) 691-4815

Other identifiers 5

IdentifierTypeStateIssuer
014174OtherVIP
17691OtherMEDICARE
35458OtherAVESIS
42575OtherDAVIS
CP230-16OtherEYEMED

Other names 1

  • ShopKo Optical 174 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Shopko Pharmacy 217916 organizations share this tax ID, including this one

Other organizations with this tax ID 15

Organizations that report the same tax identification number in the National Provider Directory.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1190937600000",
    "number": "1073565180",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2323 W PIONEER PKWY",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616151833",
            "telephone_number": "309-691-4815"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2323 W PIONEER PKWY",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616151833",
            "telephone_number": "309-691-4815"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "last_updated": "2007-09-28",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "SR. VICE PRESIDENT HEALTH SERVICES",
        "authorized_official_telephone_number": "920-429-4297",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014174",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "17691",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35458",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS",
            "identifier": "42575",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP230-16",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 174",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.