Provider Demographics
NPI:1790039345
Name:SHOPKO PHARMACY
Entity Type:Organization
Organization Name:SHOPKO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAWEK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-323-8134
Mailing Address - Street 1:1625 E BLASCHKO AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:WI
Mailing Address - Zip Code:54612-1835
Mailing Address - Country:US
Mailing Address - Phone:608-323-8134
Mailing Address - Fax:608-323-8434
Practice Address - Street 1:1625 E BLASCHKO AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1835
Practice Address - Country:US
Practice Address - Phone:608-323-8134
Practice Address - Fax:608-323-8434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy