Provider Demographics
NPI:1770536625
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:EXECUTIVE VICE PRESIDENT AND 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 1:2105 LAZELLE ST
Mailing Address - Street 2:STE 2
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-3028
Mailing Address - Country:US
Mailing Address - Phone:605-347-4553
Mailing Address - Fax:605-347-4947
Practice Address - Street 1:2105 LAZELLE ST
Practice Address - Street 2:STE 2
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-3028
Practice Address - Country:US
Practice Address - Phone:605-347-4553
Practice Address - Fax:605-347-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4305137OtherNCPDP
SD8503843Medicaid
SD9580690Medicaid
SD9165603Medicaid
SD9566700Medicaid
SD8503842Medicaid
SD9566702Medicaid
SD9165603Medicaid