Provider Demographics
NPI:1386825248
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 706
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXCUTIVE VICE PRESIDENT & COO
Authorized Official - Prefix:
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 1:111 LEROUX DR
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935
Mailing Address - Country:US
Mailing Address - Phone:573-996-2311
Mailing Address - Fax:573-996-7415
Practice Address - Street 1:111 LEROUX DR
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935
Practice Address - Country:US
Practice Address - Phone:573-996-2311
Practice Address - Fax:573-996-7415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOPKO PHARMACY 706
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-20
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy