NPIMap

Organization Active NPI

Shopko Stores Operating Co. LLC

  • Eyewear Supplier
  • Union Gap, WA
National Provider Identifier
1396797486
Registry record updated Jun 5, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
SHOPKO STORES OPERATING CO. LLC
Practice address
2530 Rudkin Rd
Union Gap, WA 98903-1632
Phone
(509) 248-9833
NPI assigned
May 17, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 2009

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

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X
OpticianGroup: 193200000X MULTI-SPECIALTY GROUP 156FX1800X
Eyewear Supplier 332H00000X Primary

Addresses

Primary practice location

2530 Rudkin Rd
Union Gap, WA 98903-1632

Mailing address

2530 Rudkin Rd
Union Gap, WA 98903-1632
Phone (509) 248-9833

Other identifiers 8

IdentifierTypeStateIssuer
G8854795OtherMEDICARE
35549OtherAVESIS
WA09209OtherWANORIDIAN SUBMITTER ID
17672OtherMEDICARE
2029924MedicaidWA
014073OtherVIP
213121-30OtherEYEMED
2200004MedicaidWA

Other names 1

  • ShopKo Optical 073 Doing business as

National Provider Directory

National Provider Directory

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": "1244160000000",
    "number": "1396797486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2530 RUDKIN RD",
            "city": "UNION GAP",
            "state": "WA",
            "postal_code": "989031632",
            "telephone_number": "509-248-9833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2530 RUDKIN RD",
            "city": "UNION GAP",
            "state": "WA",
            "postal_code": "989031632",
            "telephone_number": "509-248-9833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "last_updated": "2009-06-05",
        "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": "G8854795",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35549",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NORIDIAN SUBMITTER ID",
            "identifier": "WA09209",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "17672",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2029924",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014073",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "213121-30",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2200004",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 073",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Union Gap, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 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.