Shopko Stores Operating Co. LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

SHOPKO STORES OPERATING CO. LLC

Practice address

190 S 500 W
Bountiful, UT 84010-8729

Phone

(801) 295-9200

NPI assigned

May 19, 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 3

Addresses

Other identifiers 7

Other names 1

• ShopKo Optical 107 Doing business as

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1215648000000",
    "number": "1205889078",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "190 S 500 W",
            "city": "BOUNTIFUL",
            "state": "UT",
            "postal_code": "840108729",
            "telephone_number": "801-295-9200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "190 S 500 W",
            "city": "BOUNTIFUL",
            "state": "UT",
            "postal_code": "840108729",
            "telephone_number": "801-295-9200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2008-07-10",
        "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": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "156FX1800X",
            "taxonomy_group": "193200000X MULTI-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": "MEDICARE",
            "identifier": "17929",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014107",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NORIDIAN SUBMITTER ID",
            "identifier": "UT04877",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-53",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS",
            "identifier": "42591",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35537",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054-229",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 107",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jessica Elizabeth Sherman, PT, DPT
• Jay Glen Shields, DDS
• Russell Brent Shields, MD
• Adam Shirley
• Shopko Stores Operating Co LLC
• Kaden Earl Short
• Sydney Shuman
• Adam Gary Shurtliff, DPM
• Thomas Sicotte
• Macall Siegel

• Eyewear Supplier in Bountiful, UT
• Providers in Bountiful, UT by specialty
• Eyewear Supplier in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2008; 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.