Provider Demographics
NPI:1619928330
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 052
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 1:615 S MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5061
Mailing Address - Country:US
Mailing Address - Phone:641-424-4302
Mailing Address - Fax:641-424-8537
Practice Address - Street 1:615 S MONROE AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-5061
Practice Address - Country:US
Practice Address - Phone:641-424-4302
Practice Address - Fax:641-424-8537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
IA8193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0227249Medicaid
IA0495168Medicaid
MN743927000Medicaid
1614494OtherNCPDP NUMBER
MN201016000Medicaid
IA0227249Medicaid
IA0495168Medicaid