Provider Demographics
NPI:1376596940
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 704
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXCUTIVE 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 1:1300 STONE ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68355-2657
Mailing Address - Country:US
Mailing Address - Phone:402-245-5282
Mailing Address - Fax:402-245-5281
Practice Address - Street 1:1300 STONE ST
Practice Address - Street 2:
Practice Address - City:FALLS CITY
Practice Address - State:NE
Practice Address - Zip Code:68355-2657
Practice Address - Country:US
Practice Address - Phone:402-245-5282
Practice Address - Fax:402-245-5281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NE26933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2813574OtherNCPDP
2813574OtherNCPDP
0459230020Medicare ID - Type Unspecified