Provider Demographics
NPI:1821042003
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 615
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 1:291 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1604
Mailing Address - Country:US
Mailing Address - Phone:715-823-2350
Mailing Address - Fax:715-823-2541
Practice Address - Street 1:291 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1604
Practice Address - Country:US
Practice Address - Phone:715-823-2350
Practice Address - Fax:715-823-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33268600Medicaid
5127267OtherNCPDP NUMBER
5127267OtherNCPDP NUMBER
0459230113Medicare ID - Type Unspecified
5694490087Medicare ID - Type Unspecified