Provider Demographics
NPI:1972556926
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 753
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 1:2701 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-6601
Mailing Address - Country:US
Mailing Address - Phone:605-745-4681
Mailing Address - Fax:605-745-4813
Practice Address - Street 1:2701 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-6601
Practice Address - Country:US
Practice Address - Phone:605-745-4681
Practice Address - Fax:605-745-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123292401Medicaid
SD9162102Medicaid
4304630OtherNCPDP
SD8502040Medicaid
WY117793100Medicaid
NE47062642602Medicaid
SD9566672Medicaid
NE10025418100Medicaid
WY123292400Medicaid
SD8502042Medicaid
NE10025418100Medicaid