Provider Demographics
NPI:1184676165
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 723
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 1:2300 STATE ROUTE 534
Mailing Address - Street 2:
Mailing Address - City:NEWTON FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44444-8747
Mailing Address - Country:US
Mailing Address - Phone:330-872-1276
Mailing Address - Fax:330-872-1285
Practice Address - Street 1:2300 STATE ROUTE 534
Practice Address - Street 2:
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444-8747
Practice Address - Country:US
Practice Address - Phone:330-872-1276
Practice Address - Fax:330-872-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3660239OtherNCPDP NUMBER
OH0991502Medicaid
OH0991502Medicaid
5695760287Medicare NSC