Shopko Stores Operating Co. LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

SHOPKO STORES OPERATING CO. LLC

Doing business as

ShopKo Optical 079

Practice address

200 S 18TH Ave
Wausau, WI 54401-4252

Phone

(715) 842-8040

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 1

Addresses

Other identifiers 8

Other names 1

• ShopKo Optical 079 Doing business as

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

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202688000000",
    "number": "1386697092",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 S 18TH AVE",
            "city": "WAUSAU",
            "state": "WI",
            "postal_code": "544014252",
            "telephone_number": "715-842-8040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 S 18TH AVE",
            "city": "WAUSAU",
            "state": "WI",
            "postal_code": "544014252",
            "telephone_number": "715-842-8040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "last_updated": "2008-02-11",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NVA",
            "identifier": "410985054-4079",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "87857",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38440500",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35599",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014079",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-98",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS",
            "identifier": "42534",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "17670",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 079",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Nicole Marie Shinners, RDH
• Michaele Lee Shipway, M.S.W., L.C.S.W.
• Crystal H Shirek, PA-C
• Solomon Shockman, MD
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 079)
• Shoptikal LLC (Shopko Optical 4079)
• Paul T Shore, DDS
• Joshua Shupe, MD
• Derrick Robson Siebert, M.D.
• Sarah Siekert, DNP, FNP-BC

• Eyewear Supplier in Wausau, WI
• Providers in Wausau, WI by specialty
• Eyewear Supplier in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 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.