Provider Demographics
NPI:1689626970
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 683
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT & COO
Authorized Official - Prefix:MR
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 1:109 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1173
Mailing Address - Country:US
Mailing Address - Phone:712-563-3302
Mailing Address - Fax:712-563-3404
Practice Address - Street 1:109 N MARKET ST
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1173
Practice Address - Country:US
Practice Address - Phone:712-563-3302
Practice Address - Fax:712-563-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0433367Medicaid
1621920OtherNCPDP
IA0495895Medicaid
IA0433367Medicaid