Provider Demographics
NPI:1376842286
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP & COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:700 PILGRIM WAY
Mailing Address - Street 2:PO BOX 19060
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5263
Mailing Address - Country:US
Mailing Address - Phone:920-429-7137
Mailing Address - Fax:920-429-4649
Practice Address - Street 1:705 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2168
Practice Address - Country:US
Practice Address - Phone:763-389-3111
Practice Address - Fax:763-389-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MN263663333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2430786OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN1376842286Medicaid
MN1376842286Medicaid