Provider Demographics
NPI:1962458315
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 042
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:1300 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6169
Mailing Address - Country:US
Mailing Address - Phone:920-426-5770
Mailing Address - Fax:920-426-1708
Practice Address - Street 1:1300 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6169
Practice Address - Country:US
Practice Address - Phone:920-426-5770
Practice Address - Fax:920-426-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X, 333600000X
WI86260423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5116923OtherNCPDP NUMBER
WI33045600Medicaid
WI33045600Medicaid
5695760125Medicare NSC