Shopko Stores Operating Co. LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

SHOPKO STORES OPERATING CO. LLC

Practice address

3499 E Fairview Ave
Meridian, ID 83642-5848

Phone

(208) 884-1362

NPI assigned

May 18, 2006

Organization subpart

No

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 2

Addresses

Other identifiers 8

Other names 1

• ShopKo Optical 169 Doing business as

Locations

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

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1249257600000",
    "number": "1184677759",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3499 E FAIRVIEW AVE",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836425848",
            "telephone_number": "208-884-1362"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3499 E FAIRVIEW AVE",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836425848",
            "telephone_number": "208-884-1362"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-18",
        "last_updated": "2009-08-03",
        "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": "156FX1800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Technician/Technologist, Optician",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-11",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014169",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "1593902",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "17840",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805542700",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35448",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806430108",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS VISION",
            "identifier": "42568",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 169",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jazzmine Shinn
• Andrew Lewis Jend Shirk, DPT
• Marissa Shirley, PHARMD
• Matthew Claibourne Shonnard, MD, MPH
• Shopko Stores Operating Co LLC
• Tucker Short
• Alexander Shriver
• Laura Ann Shukla, P.T.
• Erin Marie Shumard
• Daniel Charles Shumway

• All providers in Meridian, ID
• Eyewear Supplier in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2009; 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.