Provider Demographics
NPI:1881647840
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 749
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 1:301 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-1723
Mailing Address - Country:US
Mailing Address - Phone:507-375-8115
Mailing Address - Fax:507-375-8357
Practice Address - Street 1:301 1ST AVE S
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MN
Practice Address - Zip Code:56081-1723
Practice Address - Country:US
Practice Address - Phone:507-375-8115
Practice Address - Fax:507-375-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
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
MN728113000Medicaid
MN891450800Medicaid
2424276OtherNCPDP
5695760199Medicare NSC
MN891450800Medicaid