Provider Demographics
NPI:1851345060
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 696
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND 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 1:505 W HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:KS
Mailing Address - Zip Code:67654-1247
Mailing Address - Country:US
Mailing Address - Phone:785-877-2133
Mailing Address - Fax:785-877-2748
Practice Address - Street 1:505 W HOLME ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:KS
Practice Address - Zip Code:67654-1247
Practice Address - Country:US
Practice Address - Phone:785-877-2133
Practice Address - Fax:785-877-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200389320DMedicaid
NE10025417900Medicaid
1718040OtherNCPDP
KS200389320CMedicaid
NE10025036200Medicaid
KS100643240AMedicaid
1718040OtherNCPDP