Provider Demographics
NPI:1013946250
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 647
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 1:1101 N INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-1019
Mailing Address - Country:US
Mailing Address - Phone:574-457-3109
Mailing Address - Fax:574-457-3186
Practice Address - Street 1:1101 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-1019
Practice Address - Country:US
Practice Address - Phone:574-457-3109
Practice Address - Fax:574-457-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1536690OtherNCPDP
IN200445250AMedicaid
IN200445250AMedicaid
0459230115Medicare ID - Type Unspecified