Provider Demographics
NPI:1265485858
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 668
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 1:660 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50659-1013
Mailing Address - Country:US
Mailing Address - Phone:641-394-6404
Mailing Address - Fax:641-394-2958
Practice Address - Street 1:660 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-1013
Practice Address - Country:US
Practice Address - Phone:641-394-6404
Practice Address - Fax:641-394-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0446930Medicaid
1622136OtherNCPDP
IA0495580Medicaid
IA0446930Medicaid
I20053Medicare PIN