NPIMap

Organization Active NPI

Shopko Stores Operating Co. LLC

Doing business as ShopKo Optical 502

  • Eyewear Supplier
  • Green Bay, WI
National Provider Identifier
1861445405
Registry record updated Feb 11, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
SHOPKO STORES OPERATING CO. LLC
Doing business as
ShopKo Optical 502
Practice address
2585 Lineville Rd
Green Bay, WI 54313-7122
Phone
(920) 662-9450
NPI assigned
May 17, 2006
Last updated
Feb 11, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2008

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

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X NU Primary

Addresses

Primary practice location

2585 Lineville Rd
Green Bay, WI 54313-7122

Mailing address

2585 Lineville Rd
Green Bay, WI 54313-7122
Phone (920) 662-9450

Other identifiers 6

IdentifierTypeStateIssuer
50115OtherDAVIS
014502OtherVIP
CP2230-71OtherEYEMED
25866OtherMEDICARE
38723100MedicaidWI
410985054-4502OtherNVA

Other names 1

  • ShopKo Optical 502 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": "1202688000000",
    "number": "1861445405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2585 LINEVILLE RD",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543137122",
            "telephone_number": "920-662-9450"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2585 LINEVILLE RD",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543137122",
            "telephone_number": "920-662-9450"
        }
    ],
    "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS",
            "identifier": "50115",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014502",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-71",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "25866",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38723100",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NVA",
            "identifier": "410985054-4502",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 502",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Green Bay, WI

Sources for this page

  • 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.