Provider Demographics
NPI:1063465854
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 657
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-5891
Mailing Address - Country:US
Mailing Address - Phone:402-426-9189
Mailing Address - Fax:402-426-9190
Practice Address - Street 1:150 S 1ST ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-2540
Practice Address - Country:US
Practice Address - Phone:402-426-9189
Practice Address - Fax:402-426-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47062642603Medicaid
2814689OtherNCPDP
IA0721886Medicaid
IA0973404Medicaid
0459230047OtherMEDICARE ID - TYPE UNSPECIFIED
NE10025417400Medicaid
NE10025417400Medicaid