Provider Demographics
NPI:1609829464
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 017
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 1:4161 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3761
Mailing Address - Country:US
Mailing Address - Phone:320-253-3280
Mailing Address - Fax:320-253-5790
Practice Address - Street 1:4161 2ND ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3761
Practice Address - Country:US
Practice Address - Phone:320-253-3280
Practice Address - Fax:320-253-5790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MN26279603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN606234200Medicaid
MN625857300Medicaid
MN0154160058Medicaid
2414249OtherNCPDP NUMBER
MN578612000Medicaid
MN578612000Medicaid
2414249OtherNCPDP NUMBER