Provider Demographics
NPI:1407807308
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 164
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:255 JOHN F KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-5313
Mailing Address - Country:US
Mailing Address - Phone:563-583-5808
Mailing Address - Fax:563-583-5804
Practice Address - Street 1:255 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-5313
Practice Address - Country:US
Practice Address - Phone:563-583-5808
Practice Address - Fax:563-583-5804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IA10703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619696OtherNCPDP NUMBER
WI33236500Medicaid
IA0495309Medicaid
IA0181107Medicaid
IL410985054164Medicaid
IL=========006Medicaid
WI33236500Medicaid
IL410985054164Medicaid