Provider Demographics
NPI:1477504793
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 082
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MISS
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 1:5959 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7222
Mailing Address - Country:US
Mailing Address - Phone:801-261-3737
Mailing Address - Fax:801-261-0702
Practice Address - Street 1:5959 S STATE ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7222
Practice Address - Country:US
Practice Address - Phone:801-261-3737
Practice Address - Fax:801-261-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
UT13130817033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT410985054036Medicaid
4606680OtherNCPDP NUMBER
4606680OtherNCPDP NUMBER
5695760045Medicare NSC
4606680OtherNCPDP NUMBER