Provider Demographics
NPI:1114113511
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 776
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 1:925 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREYBULL
Mailing Address - State:WY
Mailing Address - Zip Code:82426
Mailing Address - Country:US
Mailing Address - Phone:307-765-4601
Mailing Address - Fax:307-765-4600
Practice Address - Street 1:925 N 6TH STREET
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426
Practice Address - Country:US
Practice Address - Phone:307-765-4601
Practice Address - Fax:307-765-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125144900Medicaid
5695760223Medicare NSC