Shopko Optical 4069 is a medicare enrolled "Eyewear Supplier" provider in Coeur D Alene, Idaho. Their current practice location is
212 W Ironwood Dr Ste B&c, Coeur D Alene, Idaho. You can reach out to their office (for appointments etc.) via phone at
(208) 765-8078.
Shopko Optical 4069 is licensed to practice in * (Not Available) (license number ) and it also participates in the medicare program. Shopko Optical 4069
is enrolled with medicare and should accept medicare assignments and since they are enrolled in medicare, they may order Medicare Part D Prescription drugs, if eligible. The facility's NPI Number is 1063078442.
Healthcare Provider's Profile
| Full Name | Shopko Optical 4069 |
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| Type | Facility |
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| Speciality | Eyewear Supplier |
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| Location | 212 W Ironwood Dr Ste B&c, Coeur D Alene, Idaho |
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| Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
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NPI Data:
- NPI Number: 1063078442
- Provider Enumeration Date: 05/11/2019
- Last Update Date: 11/29/2024
Medicare PECOS Information:
- PECOS PAC ID: 1456684471
- Enrollment ID: O20190610000806
Medical Identifiers
Medical identifiers for Shopko Optical 4069 such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1063078442 | NPI | - | NPPES |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
|---|
| 152W00000X | Optometrist | (* (Not Available)) | Secondary |
| 332H00000X | Eyewear Supplier | (* (Not Available)) | Primary |
Medicare Reassignments
Some practitioners may not bill the customers directly but medicare billing happens through clinics / group practice / hospitals where the provider works.
Shopko Optical 4069 acts as a billing entity for following providers:
| Provider Name | Terri L Haley |
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| Provider Type | Practitioner - Optometry |
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| Provider Identifiers | NPI Number: 1114929817
PECOS PAC ID: 8022083302
Enrollment ID: I20040831000251 |
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| Provider Name | Tanya D Reid |
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| Provider Type | Practitioner - Optometry |
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| Provider Identifiers | NPI Number: 1528010121
PECOS PAC ID: 5991748402
Enrollment ID: I20050606001022 |
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| Provider Name | Martin M Harris |
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| Provider Type | Practitioner - Optometry |
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| Provider Identifiers | NPI Number: 1568710200
PECOS PAC ID: 7416252739
Enrollment ID: I20160224002852 |
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| Provider Name | Danielle Johnson |
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| Provider Type | Practitioner - Optometry |
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| Provider Identifiers | NPI Number: 1023637733
PECOS PAC ID: 2466872080
Enrollment ID: I20220725002149 |
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Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Shopko Optical 4069 is
enrolled with medicare and thus, if eligible, can prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
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Shopko Optical 4069
Po Box 19060,
Green Bay, WI 54307-9060
Ph: Not Available | Shopko Optical 4069
212 W Ironwood Dr Ste B&c,
Coeur D Alene, ID 83814-1403
Ph: (208) 765-8078 |
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