Provider Demographics
NPI:1568761484
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 605
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND 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 1:340 HIGHWAY 65 S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1619
Mailing Address - Country:US
Mailing Address - Phone:320-679-5950
Mailing Address - Fax:320-679-5956
Practice Address - Street 1:340 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1619
Practice Address - Country:US
Practice Address - Phone:320-679-5950
Practice Address - Fax:320-679-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2636623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy