Provider Demographics
NPI:1073653986
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 697
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND 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 1:1710 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:KS
Mailing Address - Zip Code:66538-1926
Mailing Address - Country:US
Mailing Address - Phone:785-336-2145
Mailing Address - Fax:785-336-2935
Practice Address - Street 1:1710 NORTH ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:KS
Practice Address - Zip Code:66538-1926
Practice Address - Country:US
Practice Address - Phone:785-336-2145
Practice Address - Fax:785-336-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200389320HMedicaid
NE10025494600Medicaid
KS200389320GMedicaid
1719117OtherNCPDP NUMBER
5694490121Medicare ID - Type Unspecified
KS200389320GMedicaid