Shopko Stores Operating Co. LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

SHOPKO STORES OPERATING CO. LLC

Doing business as

ShopKo Optical 063

Practice address

4215 Yellowstone Ave
Chubbuck, ID 83202-2419

Phone

(208) 237-6822

NPI assigned

May 17, 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 063 Doing business as

Locations

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

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1249257600000",
    "number": "1336191436",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4215 YELLOWSTONE AVE",
            "city": "CHUBBUCK",
            "state": "ID",
            "postal_code": "832022419",
            "telephone_number": "208-237-6822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4215 YELLOWSTONE AVE",
            "city": "CHUBBUCK",
            "state": "ID",
            "postal_code": "832022419",
            "telephone_number": "208-237-6822"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "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": "MEDICARE",
            "identifier": "17712",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-10",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000309500",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS VISION",
            "identifier": "42499",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806430100",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014063",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "1593901",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805180700",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 063",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Eyewear Supplier in Chubbuck, ID
• Providers in Chubbuck, ID by specialty
• 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.