Provider Demographics
NPI:1295780815
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2100 CALDWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1510
Mailing Address - Country:US
Mailing Address - Phone:208-466-9616
Mailing Address - Fax:208-463-1724
Practice Address - Street 1:2100 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1510
Practice Address - Country:US
Practice Address - Phone:208-466-9616
Practice Address - Fax:208-463-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
ID2042CP333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000311800Medicaid
0215801OtherWA LABOR & INDUSTRY
0193994OtherWA LABOR & INDUSTRY
1304524OtherNCPDP NUMBER
1111590020Medicare ID - Type Unspecified
5695760006Medicare NSC